In the 26th report (2009-10) the question was asked:
Suppose a person has a painful incurable disease. Do you think that doctors should be allowed by law to end the patient’s life, if the patient requests it?
Results
Posted in Facts and Arguments, The story so far
What are the moral issues inherent in Assisted Dying?
From: Ella Lewis Jones
I cannot but have reverence for all that is called life. I cannot avoid compassion for all that is life. That is the beginning and foundation of morality.
Albert Schweitzer: Reverence for Life
Most of us, were we to be given the choice, would choose a ‘good death’, that is an end to our life that was dignified, without fear and undue pain. Unfortunately, for far too many, their passing is often marked by intolerable physical and mental suffering, with their relatives and loved ones feeling helpless and inadequate to relieve the suffering. In his book ‘Health is for People’, written more than fifty years ago, the author the Rev Dr Michael Wilson suggests, and I paraphrase, ‘it seems that within the Medical Profession today there is a strong belief that the worst thing that can happen to a man is that he should die’. In the years that have followed more and more resources have gone into prolonging life, seemingly regardless of its quality, so much so that even if we accept that individuals have a right to their life, even in the most dire physical or mental condition, we have to ask ourselves, in the face of what often appears to be overzealous treatment ‘do we not also have a right to die’? There are many who believe that there is an important moral difference between ‘acts and omissions’ in medical care, that is, a difference, between killing and ‘not striving to keep alive’.
If, as I have implied, there are circumstances in which it is morally right to help to end the life of someone who wants to escape a life which to them is intolerable, then the question is whether the law could be changed to make this not only morally right but legally permissible.
Although every society subscribes to some principles which prohibit the taking of life there are great variations between cultural traditions as to when the taking of life is considered to be wrong. It was Judaism and the rise of Christianity which contributed substantially to the general feeling that human life has sanctity and as such must not deliberately be taken. ‘The Sanctity of Human Life’ principle has many supporters, not all religious, and it is based on the view that it is always better to be alive than dead even if one passionately wants to die. It is the sanctity of human life argument which is used predominantly by those who wish to prohibit any change in the law to permit assisted death.
There are two primary reasons which are given for the moral permissibility of assisted death which are motivated by compassion for hopelessly ill and suffering patient(s) and/or out of respect for individual autonomy and a person’s right to end their life if they so wish. The meaning of autonomy is making one’s own laws, and adopting one’s own principles. The principle of autonomy is generally regarded as the basis upon which those who wish to see a change in the law base their case.
Medical students today are taught about the principle of patient autonomy in their compulsory ethics courses. The principle of autonomy is one of the four which are considered to be at the root of medical ethics. The four principles are beneficence (the doctor must be well-intentioned towards his patient and aim to do good): non-maleficence (the doctor must avoid harming his patient): autonomy (the doctor must treat his patient as a rational human being capable of making choices and possessed of free will): and justice (the doctor must distribute resources, including time and skill, fairly between his patients. (Beauchamp & Childress 1994) These principles e.g. autonomy and justice can be in conflict when financial resources are finite and expensive drug treatments are given to one patient which leaves less resources for other patients. Doctors are taught these principles so that when they cannot decide what they ought to do in the best interests of their patient they have an ethical framework within which they can consider their decision.
In cases of extreme pain which is impossible to alleviate a doctor whilst administering pain-relieving treatments can unintentionally bring about death. This is termed, a ‘double effect’. The doctrine of ‘double effect’ can be crudely stated as the view that it may be permissible to perform a good act with some unforeseeable bad consequences, but, and this is what causes many doctors a serious moral dilemma, that it is wrong to do a bad act for the sake of good consequences that will follow. In practice, this doctrine has been cited as the reason for doctors withholding pain relief for fear of killing the patient. Although a doctor’s training forbids the termination of a patient’s life the interpretation of the patient’s ‘best interest’ has evolved and now takes into account, at a much more fundamental level, the notion of the patient as a person with a right to decide on important matters concerning his/her own health.
However, even for doctors who support the primacy of patient autonomy, there have to be legitimate limits to patient choice. A patient, for instance, cannot force a doctor to give him the treatment of his choice, if in the doctor’s judgement the treatment will be futile. Nor can the patient’s preferences outweigh the doctor’s superior professional knowledge and expertise. Moreover a Doctor should have the right, if conscience dictates, to decline involvement in euthanasia or assisted suicide, in the same way as conscientious objection to participate in abortion has been respected. The difficulty lies in determining precisely where the limits of the doctor’s involvement should be drawn. Doctors are committed to saving life, sometimes, for a variety of reasons some patient(s) may wish to die.
One of the considerable concerns, which to date has not been resolved to the satisfaction of either the legal establishment or many members of the general public, which even those who accept the need for a change in the law on compassionate grounds recognise, is the genuine concern that any legislation which is formulated, however humane the intentions, could, in the future, be abused by the unscrupulous. These arguments against any relaxation in the law on assisted dying are described in ethical terms as the “Slippery Slopes”. The slippery slope is a variant of the well-known principle of the dangerous precedent. In other words, in relaxing the law so that those who wish to end their life on compassionate grounds can be allowed to die we will also be opening the legal ‘gates’ so that those who have not asked to die could have their lives deliberately ended. There are a number of potential problems which are often cited in “Slippery slope” arguments. To give some examples: If the law on assisted dying is changed, will the funding and research on Palliative Care be considered unnecessary or be reduced? Will children, impatient either for their inheritance or simply for relief from the burden of care, put pressure on their relative(s) to seek an early death? Will anyone who has an incapacitating or intractable physical or mental condition be pressured into seeking their own death to lessen the burden on society? Or will trust between a patient and their Doctor be eroded if Doctors are permitted to assist death?
Recent evidence has shown that in both Oregon and the Netherlands where euthanasia is permitted, rates of assisted dying show no evidence of heightened risk for several vulnerable groups, notably the disabled, the elderly, and those with a psychiatric illness. Thus, where assisted dying is already legal there is no current evidence for the claim that legalizing assisted dying will have a disproportionate impact on vulnerable patients and put them at risk of undue pressure to agree to end their lives. Nevertheless, regardless of the fact that many of the above arguments are speculative, it behoves us to ensure that any legislation which permits assisted dying should, in so far as it is humanly possible, contain sufficient legal safeguards to protect the individual and ensure that the law is not abused.
References
Beauchamp T.L & Childress J.C. (1994) Principles of Biomedical Ethics OUP
Glover J (1990) Causing Death and Saving Lives Penguin
Harris J (1991) The Value of Life Routledge
Singer P Edt (1993) A Companion to Ethics Blackwell
Warnock M & Macdonald E (2009) Easeful Death Oxford
Further Reading
Arditti M (2010) The Enemy of the Good Arcadia
Ella Lewis Jones has an MA in Medical Ethics and is a member of the Aberdare congregation
Posted in Facts and Arguments
The Law in the United Kingdom
Suicide Act 1961
This Act amended the law of England and Wales [3rd August 1961]. It is quite unusual in that section 1 determined that suicide would cease to be a crime, but section 2 made it a criminal offence to be complicit in another’s suicide, so that a person who aids, abets, counsels or procures the suicide of another, or an attempt by another to commit suicide, is liable on conviction to imprisonment for a maximum of fourteen years. The other important part of section 2 is that no proceedings can be instituted except by or with the consent of the Director of Public Prosecutions.
The Purdy case
Debbie Purdy, who suffers from multiple sclerosis, instituted civil proceedings which eventually went to the House of Lords in order to determine whether her husband would be prosecuted for assisting her commit suicide. In passing judgement in 2009, the Law Lords instructed the Director of Public Prosecutions to publish the policy for prosecutors.
Summary of Policy for Prosecutors in Respect of Cases of Encouraging or Assisting Suicide
The guidelines seek to differentiate between malicious acts and compassionate acts. There are no absolutes in the guidelines, but …
Factors tending toward prosecution would be if the ‘victim’ (who died) was aged under 18, a lack of mental capacity, no clear, voluntary settled decision, no clear communication of the decision, no seeking of encouragement, outside pressure, or if the ‘suspect’ (who helped them) had a history of violence or abuse, was unknown to the victim or gave encouragement to more than one victim, was paid or was a healthcare professional or professional carer.
Factors tending against prosecution would be the victim’s clear, voluntary settled and informed decision, a suspect wholly motivated by compassion who gave only minor encouragement or assistance and who had sought to dissuade the victim as well as giving their full co-operation to the police.
Legal difficulties with the present law in the UK
The following contributions were made to the Falconer Commission and have been selected to highlight some of the problems with the existing law and the associated DPP guidelines:
Dignity in Dying – The prosecuting policy cannot provide sufficient safeguards to protect people, because all the checks take place after a person has died, when it is too late to prevent potential abuse. In contrast, the assisted dying legislation that we propose would provide ‘up front’ checks and safeguards when someone requests help to die.
Professor Penney Lewis – Without having any restriction on the victim’s condition or experience, for example his or her experience of suffering, the policy is now more liberal than most permissive regimes and fails to distinguish between on the one hand a terminally ill victim who is experiencing unrelievable suffering and a victim who is suffering from depression.
DPP – We thought that if the law remains unamended and in that form, it was important to distinguish between as it were one off acts of support and compassion and those that were engaged in the delivery of professional services or a business that would routinely, or be more likely to routinely bring them into conflict with the law, because of the broad prohibition on assisted suicide…it’s one thing to say, ‘this is a one off compassionate act’ compared with ‘this is the provision of a service or a business’, which inevitably involves a breach in the law.
Nursing and Midwifery Council – The issue for us is that you are a registered nurse and there are particular clauses within the code that certainly require you to uphold the law under any circumstances, but they also require you to uphold the good standing of the profession, whether you are on duty or not. So it’s an important emphasis to make that you can’t just switch that off and say ‘Well, I’m not nursing now, I’m down the pub, I’m going to do something outrageous, I don’t care.’ Well if that brings the profession into disrepute, we might well take a view on it and there are a lot of very different circumstances that will be taken on.
General Medical Council – The principle in Good Medical Practice is that doctors need to follow the law so the fact that the DPP doesn’t prosecute does not mean that the doctor has not acted unlawfully.
PAVA UK – There is a general issue throughout this matter that relates to ‘vulnerable adults’ who are ‘the suspect’ as opposed to ‘the victim’. Adults with learning disability, a sensory impairment of a mental health problem could be put into a position of ‘assisting’ someone else commit suicide without being fully aware of what they are doing while lacking the capacity to understand if fully informed.
About a recent case in NE England – The two people who accompanied him are still on police bail, 6-8 months later. Although they, I think, won’t be prosecuted, it’s very hard to grieve for somebody when you have had your house turned over and you’re on police bail for something.
Alan Cutkelvin Rees – The police took my DNA, my photograph and my fingerprints and I’m now in the process of trying to get them removed from the database because I consider that I’m not a criminal and I’ve done nothing wrong.
The Law in Other Countries
• US States of Oregon and Washington
Oregon (1997) & Washington (2008) – and currently being proposed in Montana
An individual who is 18 years of age or older who is capable, is a resident of Oregon or Washington, and has been determined by a physician to be suffering from a terminal disease, and who has voluntarily expressed his or her wish to die, may make a written request for medication for the purpose of ending his or her life in a humane and dignified manner. A valid request for medication under this Act must be signed and dated by the patient and witnessed by at least two individuals who, in the presence of the patient, attest that to the best of their knowledge and belief the patient is capable, acting voluntarily, and is not being coerced to sign the request.
If in the opinion of the attending physician or the consulting physician a patient may be suffering from a psychiatric or psychological disorder, or depression causing impaired judgment, the physician must refer the patient for counselling. No medication to end a patient’s life in a humane and dignified manner can be prescribed until the person performing the counselling determines that the person is not suffering from a psychiatric or psychological disorder, or depression causing impaired judgment.
No person shall be subject to civil or criminal liability or professional disciplinary action for participating in good faith compliance with this Act. This includes being present when a qualified patient takes the prescribed medication to end his or her life in a humane and dignified manner. No health care provider shall be under any duty, whether by contract, by statute or by any other legal requirement to participate in the provision to a qualified patient of medication to end his or her life in a humane and dignified manner. If a health care provider is unable or unwilling to carry out a patient’s health care provider shall transfer, upon request, a copy of the patient’s relevant medical records to the new health care provider.
• Switzerland
The Swiss penal code of 1937 maintains that assisted suicide is not a criminal act if the person assisting is motivated by altruistic considerations and the person assisted is a competent adult. Physicians have no special status and are therefore at liberty to play a part in assistance, particularly as a doctor’s prescription is needed if lethal medication is required. Direct, active euthanasia (deliberate killing in order to end the suffering of another person) is forbidden. By contrast, both indirect, active euthanasia (the use of means having side-effects that may shorten life) and passive euthanasia (rejecting or discontinuing life-prolonging measures) – while not governed by any specific statutory provisions – are not treated as criminal offences provided certain conditions are fulfilled.
• Netherlands
In the Netherlands, the Termination of Life on Request and Assisted Suicide (Review Procedures) Act took effect on April 1, 2002. It legalizes euthanasia and physician assisted suicide in very specific cases, under very specific circumstances. The procedures codified in the law had been a convention of the Dutch medical community for over twenty years.
The law allows medical review board to suspend prosecution of doctors who performed euthanasia when each of the following conditions is fulfilled:
• the patient’s suffering is unbearable with no prospect of improvement
• the patient’s request for euthanasia must be voluntary and persist over time (the request cannot be granted when under the influence of others, or of psychological illness or drugs)
• the patient must be fully aware of his/her condition, prospects and options
• there must be consultation with at least one other independent doctor who needs to confirm the conditions mentioned above
• the death must be carried out in a medically appropriate fashion by the doctor or by the patient, in which case the doctor must be present
• the patient is at least 12 years old (patients between 12 and 16 years of age require the consent of their parents).
The doctor must also report the cause of death to the municipal coroner in accordance with the relevant provisions of the Burial and Cremation Act. A regional review committee assesses whether a case of termination of life on request or assisted suicide complies with the due care criteria. Depending on its findings the case will either be closed or, if the conditions are not met, brought to the attention of the Public Prosecutor. Finally, the legislation offers an explicit recognition of the validity of a written declaration of will of the patient regarding euthanasia (a “euthanasia directive”). Such declarations can be used when a patient is in a coma or otherwise unable to state if they wish to be euthanized.
Euthanasia remains a criminal offense in cases not meeting the law’s specific conditions, with the exception of several situations that are not subject to the restrictions of the law at all, because they are considered normal medical practice:
• stopping or not starting a medically useless (futile) treatment
• stopping or not starting a treatment at the patient’s request
• speeding up death as a side-effect of treatment necessary for alleviating serious suffering.
Euthanasia of children under the age of 12 remains technically illegal; however, Dr. Eduard Verhagen has documented several cases and, together with colleagues and prosecutors, has developed a protocol to be followed in those cases. Prosecutors will refrain from pressing charges if this Groningen Protocol is followed. Source: WikiPedia
• Belgium
The “Euthanasia Act” legalized euthanasia in Belgium in 2002, but it didn’t cover assisted suicide.
In 2006, Belgium legalized partial euthanasia with certain regulations.
The patient must be an adult and in a “futile medical condition of constant and unbearable physical or mental suffering that cannot be alleviated”:
• Patient must have a long-term history with the doctors, resulting in euthanasia/physician assisted suicide only being allowed for people residing in the country
• There need to be several requests that are reviewed by a commission and approved by two doctors. Source: WikiPedia
• Luxembourg
Euthanasia and assisted suicide were legalized in April, 2009, after failing to get royal assent. In December 2008 Luxembourg’s parliament amended the country’s constitution to take power away from the Grand Duke of Luxembourg. Euthanasia is allowed for the terminally ill and those with incurable diseases or conditions, only when they asked to die repeatedly and with the consent of two doctors and a panel of experts.
• Northern Territories, Australia
The Northern Territory passed the Rights of the Terminally Ill Act in 1996. The Act was similar in scope to the Oregon and Washington, but was overturned by the Australian Parliament in March 1997 after only 9 months operation.
Posted in Facts and Arguments
From: Robert Ince
Sir Terry Pratchett
“I feel embarrassed that people from this country have to go, cap in hand, to die in Switzerland.”
I visited Dignitas in Forch (near Zurich) in the middle of May, because I happened to be there for family reasons. It seemed a good opportunity to understand things from their perspective. Well, if you want to understand, really understand, you will need to do what I had to do. Throw away all you preconceived ideas, even if you have read a lot about it…it simply isn’t like that!
Dignitas has its offices in small village outside of Zurich. No markings, just like so many other small office buildings. Here I met Silvan Luley, assistant to the General Secretary and founder, Ludwig A. Minelli.
Why was Dignitas created and what do they actually do?
Dignitas terms itself an ‘end of life society’, of which there are four major ones in Switzerland, but only two of them, Dignitas and EX International will respond to foreigners. Dignitas are the bad guys, always pushing the limits and up until recently have had a bad press. Last year there was a vote in the Canton of Zurich on two initiatives, one aiming at entirely prohibiting assisted suicide and the other intending to bar individuals from outside of Switzerland and outside of the Canton of Zürich to have access to such an option. The majorities against both propositions were so unexpectedly overwhelming that the press stopped most of it attacks and the Swiss government shelved its plans to severely tighten the law.
Dignitas is not primarily about assisted dying (they prefer the term ‘accompanied suicide’) it’s about listening to those who have reached a low point in their lives and trying to help. The majority of people they deal with are real suicide cases, people who have no life threatening medical condition, just a desire to end their lives. They get counselling much in the same way as the Samaritans in the UK would provide. Their approach is to be non-judgemental and not to be paternalistic. They certainly don’t get drugs to help them commit suicide, because that is against the law and Dignitas, if nothing else, is driven by Swiss and international Law. A few people who come to them do have a life threatening medical condition and for those people, if they are so determined, there can be help to prescribe life ending drugs. These are a small part of Dignitas’s daily care.
When we talked about the mechanics of what happens with accompanied suicide an unexpected ethical issue came to light. It is a matter of unshakeable morality that the person themselves must administer the drug and be of sound mind, otherwise it would be killing (voluntary or even involuntary euthanasia) and that is unacceptable as well as illegal.
Article 115 of the Swiss Criminal Code relating to inciting and assisting suicide was in place already from the start of this Code in 1937, but about 30 years ago, lawyers recognised that if altruistic help were offered to those in need, the law said that was not illegal. Dignitas in particular has been active in pushing the limits of the law and its interpretation. This continues today, aided by the European Convention on Human Rights. Mr. Minelli, who is a lawyer, believes that the best way to bring about change is through interpretation and further development of the law rather than political pressure. Whether he is right or not, is another matter; but he has been very successful in bringing about change.
Dignitas is an NGO, a ‘not for profit organisation’. Mr Minelli does not need the money; he was a successful journalist and lawyer for many years and, now in his late seventies, he dedicates his life to a cause he believes in so much. Interestingly enough, because of the lack of need to court personal popularity, Dignitas can appear to have a very cold and clinical approach to the end of life. This may also be as a result of Mr Minelli’s avowed atheism. Mr. Luley, on the other hand, declares himself to be agnostic, but I found a very sympathetic Unitarian soul and our conversations over the spiritual side of dying revealed this as something he wished to think more about.
Posted in Facts and Arguments
Unitarian Debate 