Assisted Suicide & the Value of Human Life

Margo MacDonald will be presenting to Parliament a Bill in draft form to legalise assisted suicide in Scotland. She has been a long campaigner for this issue and managed to secure the necessary support to prepare the Bill in draft form. Lord Advocate the Rt Hon Lord Advocate Elish Angiolini QC stated that legal guidelines on assisted suicide will not be prepared in Scotland despite of announcements on the law south of the border. "It is important to recognise the different legal landscape in Scotland, where involvement in a suicide might amount to homicide, as well as a different system of public prosecution". She said that any change in the law should “properly be a matter for the Parliament”. We are against a change in this law.

Palliative Care Bill

End of Life issues are on the agenda at the Scottish Parliament this month. Gil Paterson's proposed Palliative Care Bill has gathered enough support from MSPs to be taken forward. The draft Bill can be read here. The Scotsman published an interview with Mr. Paterson where he discusses his reasons for proposing the Bill. We are supportive of the principles of this Bill.

Care not Killing Alliance

Dr Peter Saunders, Director of Care Not Killing Alliance will be speaking on current moves to introduce assisted suicide and euthanasia into UK law,and how Care Not Killing is mobilizing support to oppose these moves. The venue is Renfield St Stephens Church Centre (Kirk Lounge)
260 Bath Street, Glasgow G2 4JP
Thursday, 5th November, 2009
8-9.30pm

End of Life issues Presentation and Service

Last night I was at the evening service at St Andrew's Parish Church in Bo'ness where members from churches in the neighbourhood met to listen to a talk on end of life issues by Dr. Murdo Macdonald. Dr Macdonald is the policy officer of the Society, Religion and Technology Project at the Church of Scotland. He presented us with a much needed update of the current legal framework for assisted suicide in Scotland and the differences between the Scottish position and the position in England. His comments were based on the End of Life Issues report to the General Assembly last year.
After the talk, there was the possibility for questions and also prayer as some of the issues talked about were intensily emotional.

The Voluntary Euthanasia view on the Living Will

The VES wishes to make the provisions of a living will binding upon the medical staff involved. They see this as a first step towards fully legaliseing eithanasia and, for the same reason they wish to see a proxy document separately legislated for, as a separate deed from a living will. No Will can 'work' without the appointment of an executor. the appointment if a 'health-care proxy' to be in effect the executor of the living will would greatly assist the effectiveness of such a document.

At present, only the person making the living will has the right to enforce it, and he is by definition incapax (incapable of making valid legal decisions). To give treatment against the expressed wishes of the patient, however, is already assault at common law, and there is therefore nothing to prevent the patient refusing in advance. The wisdom of restricting the judgement of the doctor responsible for care at this sensitive time of life is a matter which would require careful consideration. The style of living will published by the EXIT, the Voluntary Euthanasia Society of Scotland (VESS) proposes the appointment of a tutor dative (an agent appointed by the court) by the Court of Session, but this is a cumbersome and expensive procedure.





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Living Wills

An Advance Directive, is a document in which an individual lays down instructions as to health-care management and treatment to be applied in the event of their incapacity to make such decisions or convey such instructions at the time of occurrence of the circumstances envisaged. In different states in the USA there is some diversity of definition between 'Living Will' documents, 'Advance Directives' and 'health-Care proxy' documents, but the Voluntary Euthanasia Society (VES) in a careful study of the matter perceives no need to impose such distinctions. They suggest that 'Living Will' is a concept sufficiently understood to be generally used.

The Limitations of a Living Will

The popular view that a will is inviolable is not true, even in the case of a property will, and conditions which are contrary to established law or public policy cannot be enforced. This is certainly the case in the Living Will instance, since such a will cannot instist that a doctor or anyone else should put the Will-maker to death.

What do doctors think about Living Wills?
The medical view as expressed by the British Medical Association, is that a Living Will may be welcomed as an opening for the discussion of the difficult questions raised by terminal illness, and considerable use has been made of them in the context of AIDS care and counselling. neither the BMA nor the AIDS support agencies, the Terence Higgins Trust and Milestone House, nor the Association for Palliative Medicinesee any need for legislative change.





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Biblical Truth and the affirmation of Life

"No one can keep himself from dying ort put off the day of his death. That is the battle we cannot escape; we cannot cheat our way out".

Legalisation of euthanasia will not produce a solution to the needs of the individual sufferer; or address the health-care challenges of contemporary society. It is the expression of an attitude to life which belittles the sovereignty of God, diminishes the importance of sustaining relationships, and inhibits the pursuit of life-affirming answers for people in need and distress. Christians must be active in promoting positive alternatives derived from Biblical truth, so that the momentum toward intentional killing may be curbed. The Church of Scotland has an obligation before God to assert God’s interest in life, rather than in death; to exercise Christian compassion towards the sufferer, the disabled and the dying; and to encourage the relief of symptoms and improvement in the quality of life for such people. The Church cannot support euthanasia as a means to anything of these ends, and rejects the introduction of death as a treatment option in any clinical situation. Jesus said: ‘I am come that they may have Life, and that they may have it more abundantly’ (John 10:10). This declaration applies at the end of life or in the midst of distress, just as much as it does in any other circumstances, or any other time.




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How do we go about caring?

In the previous post we spoke about Christian actions in caring for at-risk people. In this post we will be providing examples of practical actions.

We can

1) Provide spiritual, emotional intellectual and physical support for the sufferer and for carers, who may be themselves 'fellow sufferers'.

2) Help to patients and carers in defining their own needs.

3) Emphasise that a relationship is being developed by the patient, the carer, medical professionals and God. This relationship is developed in the positive context of Christian HOPE. The Church can and should be taking this as a challenge since it is a matter of 'coming alongside to help'. 'Paraclete' (one called alongside to help) is the word for, and the work of, the 'Spirit of God'. 'Bear ye one another's burdens and so fulfill the law of Christ'. (Galatians 6:2).

4) Provide consistent and practical support for care establishments.

5) Facilitate the extension of the care principles applied in specialised contexts to general hospital and home care and practice. Hospices and specialist care establishments are only part of the answer.

6) Provide regular visiting and supporting the terminally ill or disabled in their homes or in hospital and meeting their specific needs as they become apparent. This si clearly as relevant for the spiritual needs of people in serious or terminal illness is as essential as the physical ministrations of medical or nursing professionals.

7) Make use of Christian 'homes'. The Lord commended this to His followers with the words 'I was a stranger and you took me in'. as well as 'I was sick and you visited me'. The CARE Home programme addresses rthis concept and relief has been given sometimes to terminally ill people themselves, but, more often, to their carers who are in need of respite. The Good Samaritan is a firther example of someone who while he did not use hos own home to receive the injured man, did apply first aid and paid the hotel charges and the treatment costs.

8) Campaign and motivate those in local and national government to improve resources; to stimulate professional bodies and organisations to take an interest in symptom relief as much as in cure; and to demand a positive alternative to the so-called 'easy option' of euthanasia, 'masterly inactivity', or therapeutic nihilism.


Credits
The photograph of the Good samaritan's stained glass window was taken by Lawrence OP.






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Christian Action in Caring for At-Risk People

It is not enough to oppose the progression of pro-euthanasia arguments, nor simply to oppose voluntary euthanasia societies and similar bodies. If the Church is not say 'no' to euthanasia, it must be ready to say 'yes' to life-affirming alternatives. The Christian Gospel is a Gospel of HOPE and in particular of hope in the context of death and hopelesness. In the situation of terminal care the challenge is to bring effective relief within the context of Christian hope. It has been characteristic of the Church though the ages that it has been in the forefront of work for the suffering, the dying, and the hopeless. The hospice movement owes its existence largely to Christian initiatives which, while they have been followed by secular involvement, remain a positive motivation.

The roots lie in the need for Christians to do, rather than merely protest. A belief in the eternal worth and dignity of human beings is the mark of the Christian since the Lord Himself gave the worth of His own life and death to each one and afforded us the dignity of His eternal love.

Where the elderly, the disabled, the dying and the dementing are held in respect as fellow human beigns, they cease to be seen in negative terms. They also cease to be seen as an alien 'other' kind of person for whom the best thing is to give up on life, but are valued as individuals and to the Christian as individuals for whom Christ died. To quote from Dr. John Wyatt, a prominent paediatric specialist:

In summary, Biblical Christianity does not devalue individuals becuase of their disability. In fact, from a Christian perspective, all of us are disabled in some sense.... and the differences between us are therefore only iun degree. The essence of humanity is not in our functional ability, which may be impaired rto a greater or lesser extent, but in our creation as beings made in God's image. Functional impairment in itself does not impair our dignity or worth as human beings. The central purpose of human life is seen not in the selfish pursuit of pleasure through use of our bodily functions, but in mutual loving relationships with others and with God Himself. In Christian terms it is these personal relationships of love and self-giving which give life its 'quality'. (Survival of the wakest: CMF Publication).

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The Christian Response

We have been discussing issues relating to the availability of euthanasia for children. It is therefore appropriate to ask what is the Christian approach to this difficult topic. The traditional Christian approach is as follows:

1. Palliative Care with response and resources and higher motivation.
2. Better communication in respect of the child, taking account of the need for counselling and a recognition and respect for the child, equally, as a person formed in the image of God.
3. Valid motivation: the phrase ‘compassion mingled with respect’, attributed to Mother Teresa, perhaps sums up the most constructive attitude and is very much in keeping with the spirit of the Lord’s words – ‘In as much as ye did it unto one of the least of these, my brothers, ye did it unto me’ (Matthew 25:40). The irreducible minimum of care was defined as – fluid and nutrition, analgesia and tender loving care (TLC). If a community is to claim to be civilised, it must care for its disadvantaged.

Here are some references if you wish to read more on the subject.

H Tristram Engelhardt, A Smith Iltis (2005)
End-of-life: the traditional Christian view.The Lancet.

RM Hare(1975)
Euthanasia: a Christian view.Philosophic exchange





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The factors in change in paediatrics

Five general changes were noted as influencing practice in children:

1 Technical advances, making things possible which could not happen before – often bringing problems as well as advantages

2 The possibility of assigning prognosis to conditions found by screening raises the problem of information being available which it may not be appropriate or helpful to possess (e.g. a bad prognosis given ante-natally, which is not fulfilled post-natally may have a negative effect upon parental attitude towards the child). This is important because a high rate of false positive results is encountered in screening procedures. Unless action is to be taken on the results of the screening – e.g. termination of pregnancy – the screening may be counter-productive.

3 The new consumerism has an effect upon attitudes when things go wrong with the neonate. Society, as well as the individual, are seeking control of life’s events; technology seems to offer this, including control of the arrival of children on time and perfect. A baby may be viewed as a ‘consumer product’ or accession and biological variation may not be acceptable: a view which leads readily to the attitude – ‘if it is not right, dispose of it’.

From the Christian perspective, GOD has control – we do not. Our lives are in God’s hands at the beginning and the end. Human goal setting, ambition and consumerism must give way to our accountability and stewardship of life and relationships, for which we are answerable to God Himself. The question, ‘Am I my brother’s keeper?’, still evokes the answer ‘yes!’ from the highest authority in the matter.

4 Secular philosophy – discussed above – proposes the idea that babies are potential people, not real people. They are capable of life to the full, but if they are seen as not ‘capable’, they are likely to be considered disposable.

5 Health-care economics. Pressure on resources requires allocation of priorities. Babies may not be seen as a priority, especially if deformed or abnormal! Economics asks the question, ‘Is this expense good value for money?’.





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Neo-natal care

The specialist field of neonatology came into being to meet the needs of infants delivered in difficult midwifery situations. Low birth weight (premature) children - less than 3.5lbs - account for about 1% of births and survival for such children before specialist intervention occurred was bout 25%. this is now around 75%.

Malformed children account for about 1-2% of all births and, with the important exception of brain malformations, the prognosis for normal life for many of these children is fairly good as neonatal intensive care and surgery have improved. Many previously lethal malformations are treatable with good out6come if diagnosis is made early, and detection techniques are imporving so that early treatment is made possible.

Professional attitudes to this type of work are ambivalent. Some consider these infants as 'nature duds' and would not feel that any treatment was appropriate, especially in view of the high costs involved. 'Foetal medicine' - concerned maily with screening ofr abnormality and termination of pregnancy, if such abnormality is found - has been developing in parallel. In this context it is permissible both in Scots law, and more recently in English Law, to terminate a pregancy for reasions of severe foetal abnormality right up to term.

It has been observed that in deciding how much should be done in such cases of malformation and birth abnormality, a good deal of reliance may be placed on the intuitive responses of parents and others involved, since the general philosophy is still towards the concept of sanctity of life. This may pwe something to the general awareness of a Judaeo-Christian heritage and background.

In some areas of secular philosophy, however, opinions may differ markedly from this approach. Some would express the idea that a child is not yet fully a person, but only a potential person and therefore should have no rights until it has self-awareness. This view is reminiscent of the arguments about personhood in the abortion debate. It is striking that ethicists seem to differ quite markedly from the general public in these matters.

Additional Readings

It is not always possible to provide links to the full texts of related documents to the posting, however whenever possible, I am including links to the abstracts.

Sklansky, M. (2001). Noenatal Euthanasia: Moral Considerations and Criminal Liability. Journal of Medical Ethics.

Kon, AA. (2007). Neonatal Euthanasia is unsupportable: the Groningen protocol should be abandoned. Abstract available here.

Costeloe, K. (2007) Euthanasia in Neonatals. Abstract available here.

This link details to choice made by a mother concerning a screening during her pregnancy.




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Petition opposing Legalisation of assisted suicide

Hannnah Caldwell, from CNK Alliance LTD is asking for support towards a petition against the legalisation of Assisted Suicide in the UK. Here is what she has emailed us.

We invite you to sign the following petition opposing the legalisation of assisted suicide. The petition is available in the following link


It declares: "We the undersigned petition the Prime Minister to retain the
law that makes it a criminal offence to assist another person to commit
suicide".

Thank you for supporting the Care Not Killing Alliance and our efforts to promote palliative care and to oppose euthanasia.

Best wishes,

Hannah Caldwell
Administrator, CNK Alliance Ltd

.



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The Demand for Euthanasia for Children

There is no demand from parents for intentional killing and the matter is raised more by ethicists and theoreticians than by anyone in the practical field. The majority of paediatricians are against intentional killing and medically assisted suicide, but there is a small group who would support its introduction.

One report indicates that children have been supplied with a lethal injection and have been encouraged to administer this to themselves 'when all eslse has failed'. In such a situation, you wonder whether compassion and care had indeed failed the child!

Unconscious Children
These are usually sufferers from trauma, head injury, and brain lesions of various kinds. The most freqeunt problem encountered is head injury related to traffic accidents. They have often been dealt withi in adult intensive care units until recently, when paediatric units have been opened. The criteria for brainstorm death are the same as in adults. Similar debates occur over brainstem death in children as in adult cases. 'Switch-off' decisions are generally made on the same grounds of negative expectation of recovery, but practice varies.

The parents have the veto and often wish to continue life support initially, but may reach a point of acceptance of the futility of this after an opportunity to come to terms with the realities of the situation. Improved resucitation techniques have really introduced these problems, since many would have died without these being applied.

Where the life support requires to be switched off, this is usually done with the parents present, one of them helding the child in the period after the switch off.

The normal expectation is that death will occur. However the expectation of death may not always be fulfilled, and a brain damaged child requiring a major level of support remains. In one incident following which the child was fosteres in a loving home with excellent care, major guilt still produces problems for the parents. The case for euthanasia in such cases would rest more upon the suffering of the parents rather than that of the child.

Additional readings
Some of these readings might be useful
Shepperdson, B. (1983). Abortion and Euthanasia of Down's Syndrome Children. the Parents view.

Journal of medical Ethics

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Engelhardt, T (1989). Ethical Issues in Aiding the Death of Young Children.An excerpt is available here.

Macdonald WL (1998)> Situational factors an attitudes towards voluntary euthanasia. The abstract is available here.





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Euthanasia in Childhood and Infancy

In the practice of paediatric medicine there are two main areas in which eithanasia may be relevant-paediatric terminal illness and neonatal intensive care.

Paediatric terminal illness: the concious child.
Most conscious children requiring terminal care are cancer patients, but some have meningitis or other progressive conditions. Palliative care for these has recently received new emphasis, as expansion in the filed with specialised hospice provision for children has occurred. By contrast in Holland, where the euthanasia concept is widely accepted, there is no such specialist provision. Euthanasia is overtly perceived as the solution to these problems.

The emotional aspects of caring for a dying child are difficult for parents and for staff to handle, irrespective of the symptoms of the condition. Carers must consider the autonomy of children, as well as considering them as people who do have a right and a need to know what is happening to them in terms which they can understand. A child, like an adult has the right to have wishes, feelings and preferences and to express them.

It is responsible and necessary to give factual information to a child as much as to an adult, and experience has shown that children may handle the terminal care situation better than many adults. Family involvement, which includes siblings in decisions results in easier relationships and management of difficult situations. counselling of a whole family is often necessary and involvement of other children in family grief has a healing effect. Long family silence about a dead child is found to be common, but it may have a destructive effect.

Adequate symptom relief, sometimes self-administered and controlled by the child (who can become very skilled at it) and support for the family through the time of trauma, result in the elimination of the need for intentional killing.

The following websites have relevant information about this topic.
Terminal illness
Child Trust Fund
Facing Bereavement

Credits
The picture of the sick child was taken by Shainlee

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Alternatives to the Progression of Euthanasia

There is increasing evidence that requests for euthanasia come from patients whose sympotm control has been less than adequate, and these requests are very rarely sustained after good symptom control has been established. Often the demand arises out of fear of unbearable suffering. When it becomes apparent that this fear is unfounded and that relief will be available, the fear itself is allayed and the apparent need for euthanasia is diminished.

Hospice care and palliative medicine

Over the past three decades the Hospice Movement has led the way in improving the care of dying patients. This improvement has been achieved not only by in-patient units, but also, and more extensively, by the community of palliative care services provided by Macmillan Nurses and Marie Curie Nursing staff. The underlying philosophy of the movement has been the recognition of the importance of quality of life involving physical, emotional, psychosocial, intellectual and spiritual aspects of that quality.

Much of the development has been towards patients with advanced cancer, but the principles are just as appliclable to other conditions and the benefits should be available to all. Palliative care has tended to be sought by hospital as well as general practitioners, as a last resort, towards the end of the course of an illness but there is much to be said for earlier referral. The skills of palliative care require to be applied as an integral part of the management of the condition and should be considered much more often and applied at an earlier time if the greatest benefit in terms of quality of life is to be obtained.

Multi-disciplinary Caring

An integrated approach to the patient's problems is achieved best by a multi-disciplinary team which will involve medical, nursing, paramedical and other professional personnel, and the input of religions institutions is by no means irrelevant in this context. The hospital chaplain or minister may be an extremely important member of the team.

The principle challenge is to duplicate the hight standards of patient care and symptom relief as established in the field of cancer care, to influence the approach to the terminal stages of many other diseases.

Pain relief is a major issue in the quality of life.Pain relief has improved significantly even in the area of non-malignant pain which can be very debilitating and has proved more difficult to control. Pain control clinics while patchy in availability are making advances in methods and approaches to persistent pain.

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Trends relating to suicide

An increase in suicide amongst young men was reported in an article by C. Pritchard in the British Journal of Psychiatry. Several reasons for this increase have been proposed notably, lower rates of marriage, higher divorce rates, high rates of unemployment, misuse of alcohol and drugs, the threat posed by AIDS and increase risk of imprisonment. This trend has been noted in several countries of the European Community however, the increase in the rates amongst men in the 15 to 24 age group was worse in the UK when compared to the rates in most other EU countries. Unemployment has long been recognised as a major risk factor for suicide (see for example the work by Bartley and Plewis) and although the impetus for job creation schemes is often purely economic, the reality is that unemployment also has severe health implications.

The position of the Church of Scotland on suicide remains clear. It offers compassion and understanding rather than condemnation.

Credits
the photograph of the young man was taken by Dr. John
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Assisted Suicide vote in Parliament

We are starting with a series of postings by relevant academics and end-of-life activitsts who will present their own persoanl viewpoints on the ethical issues around the end of life debate. Our first panelist is Phillipa Taylor Senior Researcher, Bioethics and Family, CARE.

In late June/ early July Peers in Westminster will have a free vote on whether it should become legal to assist someone who wants to commit suicide. The Bill is the Coroners and Justice Bill which includes welcome provisions to make it an offence to encourage suicide via the web. However, attempts are being made to use this bill to change the law on assisted suicide.When the BiIl was in the Commons amendments were put down at Committee stage removing the offence of assisting someone to commit suicide but these were not put to a vote. An amendment was put down at Report Stage to allow people to help others (such as relatives) travel abroad to a country like Switzerland where they can access a suicide clinic. This amendment was not considered because parliament ran out of time, so the Bill emerged from the Commons without any change in the law. Now the Bill is in Committee Stage in the Lords and three amendments seeking to liberalise the law have been put down. Unlike in the Commons, the Lords will not run out of time so these amendments will be debated and quite possibly voted on unless the tabling peers withdraw them.

I, along with many others, believe that weakening the law on assisted suicide is unethical, unnecessary and dangerous.

1. It is unethical because the long held society-wide prohibition on intentional killing would be weakened by these amendments. Those who are tempted to commit suicide are highly vulnerable and need protection and counselling, not help in killing themselves. As the Prime Minister recently said: “It is necessary to ensure that there is never a case in which a sick or elderly person feels under pressure to agree to an assisted death or that it is the expected thing to do.” This is in stark contrast to euthanasia campaigner, Baroness Warnock, who has described dementia sufferers as “wasting people’s lives” and “wasting the resources of the National Health Service”. We should not value someone because of their “usefulness” but should recognise their inherent dignity in being human and, with compassion, seek to improve their quality of life, whilst not sacrificing the principle of the sanctity of human life.

2. It is unnecessary because, as it stands, the present law is clear, right and protects the vulnerable. Society already accepts many limits on an individual’s autonomy and personal choice for the greater good, recognising that we are not entitled to make choices which endanger the reasonable freedoms of others. For example an individual’s freedom to drive at whatever speed they like is limited in order to provide safety to others and themselves. Overturning the agreed principle of no intentional killing would have a wider impact on society, especially the vulnerable. Moreover, in most cases, good palliative care provides sufficient physical pain relief. Every patient is different, but using present techniques it is estimated that 90% of pain can be treated successfully.

It is dangerous because if Parliament accepts that people can travel abroad to assist a suicide, there will be more calls to allow assisted suicide here. Oregon, where physician assisted suicide (PAS) is legal, shows the difficulties of establishing fool proof safeguards to prevent abuse and ensure all acts of assisted suicide are truly voluntary. There is a reported lack of transparency over the practice of PAS there, minimal oversight and ineffective safeguards. In 2008, 50 per cent of patients requesting suicide were assisted to die by a doctor who had been their physician for eight weeks or less.

It is vital that the message society sends to vulnerable people should not, however subtly, encourage them to seek death, but should assure them of our care and support in life. The truly compassionate (although not always easy) and holistic response to demands for assisted dying lies in good medical treatment and in meeting patients’ physical, social, psychological and spiritual needs.

Credits
The photograph of actors around a death-bed was taken by Littlelovemonster. the picture of the house of Lords was taken by UK Parliament

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Compassion should never lead us to kill

Lord Falconer's article in The Times entitled "A more civilised approach to suicide" argues in favour of decriminalising relatives who escort a loved on to a suicide clinic abroad. He then makes an appeal for compassion for the families of the terminally ill, who are already under tremendous pressure. Compassion should never be equated with facilitation of a medically assisted death.


Compassion need not kill
The treatment of illness and the relief of suffering have advanced very considerably in the past decades. Symptom control has also made major advances. Our understanding of the nature of pain and human responses to it are increasing steadily. Pharmacological and physical methods for its relief are available and effective for conditions and circumstances which would have been previously resistant. Drug delivery systems, special formulation, chemotherapeutic agents, physical techniques such as TENS (Transcutaneous Electrical Nerve Stimulation) are pushing back the thresholds of pain and bringing relief to those who are appropriately assessed and treated.

The Ethos of Medical Practice
It is no part of the doctor's tradition or ethos to kill. This option was open in pre-Hippocratic Medicine, but Hippocratic tradition, and later, Judeo-Christian teaching set out to change this and to oblige the doctor to preserve and sustain life by every means possible. It has always been accepted that death could not be postponed indefinitely, but the duty of the doctor as expressed by Ambroise Pare 'to cure sometimes, to alleviate often, to comfort always', has stopped short of death as a treatment option. There is still in most doctors an abhorrence of killing, even accidentally, and a deeper abhorrence of doing so intentionally.

Doctors who have to deal with the very ill and terminally ill will admit to having been tempted at some time to bring a patient's life to an end. Doctors, with a few exceptions are not in the forefront of the demand for eithanasia or medically assisted suicide. They are however involved in the ethical, moral and practical issues (Lack of information, or equipment or resources) around terminal care. There is a basic need is for better clinical awareness of the principles of good management of troublesome symptoms and, as a consequence, better education and training of health-care professionals in these principles. Good clinical judgment is based on knowledge, compassion and integrity.

Ian Galloway, convener of the Church & Society Council recently presented the views of the church of Scotland in an articpublished an article on Interfaith Matters. In there he states

Pain management is a significant component within palliative care. Since its inception, palliative care education has used the model of multidisciplinary education. Palliative care is synonymous with holistic care which includes physical, psychological, social and spiritual needs. It is an approach which seeks to maximise the quality of life of patients and their families facing problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems. In recent years the provision of spiritual and religious care has benefitted greatly from multi-faith and multicultural approaches to healthcare and the move towards professionalisation of healthcare chaplaincy. If palliative care includes good spiritual care and a managed approach to pain, then some of the issues leading to calls for physician assisted suicide may be resolved.

Rvd. Galloway's views have been picked up by other bloggers.

The irreducible minimum of care has been defined as -fuid and nutrition, analgesia and tender loving care. The phrase 'compassion mingled with respect' attributed to Mother Teresa, perhaps sums up a more constructive attitude towards end-or-life issues. If a community is to claim to be civilised and compassionate it must care for those facing the last moments of their lives withou hastening that end.



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You are precious in my eyes and I love you!

By Revd Ian Galloway, Convener of Church of Scotland’s Church and Society Council has written a passionate defense of the Christian approach to end-of-life issues.

"You are precious in my eyes and I love you”. This could be the refrain of a popular love song, but it is not; it comes from the Hebrew Scriptures (Isaiah 43:4) and is one of the foundations to understanding a Christian approach to end-of-life issues. How can honour and love be at the heart of the euthanasia debate? A Christian understanding of the value of human life derives from the belief that we are made in the image of God and that God loves, honours and respects us. There is something of the sacred within each one of us. This perspective on the value of human life has particular consequences in our ageing population where there are inevitably scarce resources available to take care of the aged, the frail and the infirm. Medical advances, life-supporting technology and pharmacological solutions have increased life expectancy and the expectation of cure to the point that illness and death are perhaps less accepted as part of normal human experience.

The full article is printed in the Interfaith Matters newspaper which is the organ of the Edinburgh Interfaith Association, EIFA. The full newspaper can be downloaded here.
Reverend Galloway's article was "in print" about the same time that Margo MacDonald MSP put forward a Proposed End of Life Choices Bill to the Scottish Parliament. Since then the end of life debate has grown across the country.

On the other hand a different approach to dealing with difficult end of life issues has been proposed by Roseanna Cunningham. She presented a Proposed Palliative Care (Scotland) Bill
The Proposed Palliative Care Bill and the Proposed End of Life Choices (Scotland)Bill and can both be viewed and downloaded at the Scottish Parliament's website.
If you have any comments on the article or on any aspects of these issues please express your comments right here on the blog.










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Assisted Suicide

Assisted suicide is seen with justification, as the first step towards euthanasia. It is suggested by the supporters of euthanasia that both doctors and carers are regularly dealing with the intractable symptoms of seriously or terminally ill patients in this way, making available the means of self-destruction, but allowing the person concerned to take the definitive action which is required to end life. They call for an end to the 'hypocrisy' of this approach.

However, it is striking that in many instances of distressing and painful illness, a supply of medication which would be entirely sufficient to end life is left in the full control of the patietn with instructions for safe self-medication and in only a few cases is this trust manifestly abused. Nor is it often abused when suich instructions are given to the principal carer. It is doubtful whether the legal sanction by itself is enough to totally inhibit such action, but legalisation of physician assisted suicide would carry the same problems as the legalisation of euthanasia of any nature - it would loosen the ethical basis of much medical practice.

Legalisation of a defence of assisted suicide by relatives, carers or anyone else would be even more unsafe and would expose the caring situation to even greater pressures of a very serious nature.

Suicide and assisted suicide are neither a safe nor a satisfactory answer to the relief of a distressing illness. Thise who do promote such legislation make much of the anomaly that, while suicide has been decriminalised, assisting suicide remains a criminal act. While it may be possible to interpret the intent of the suicide - him or herself - in the light of illness or psychological disturbance, such extenuating arguments cannot be applied to tjhe person who assists. The motivation of compassion may be claimed, but many other factors mat also be playing a part, and the safeguards of the law remain appropriate.

Over the years the medical and nursing professions have steadfastly set their faces against such a change in the law, and with a few vociferous exceptions, doctors and nurses feel that they neither need it nor want it.

CreditsPhotograph by Anthea


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Conference on Patient's rights and Public Involvement in Healthcare delivery.

A conference exploring the challenges and opportunities of strengthening patient rights and public involvement in healthcare delivery will take place on Tuesday 26 May 2009, at the MacDonald Holyrood Hotel, in Edinburgh

Featured speakers include:

Margo MacDonald MSP, Author of the Proposed End of Life Choices (Scotland) Bill; Professor Kenneth Boyd, Professor of Medical Ethics and Director of Clinical Skills, Personal and Professional Development, College of Medicine and Veterinary Medicine, University of Edinburgh. Cathy Jamieson MSP, Shadow Cabinet Secretary for Health and Wellbeing; Professor John Smyth, Assistant Principal, Cancer Research Development, University of Edinburgh.

The Scottish Government's vision for a ‘mutual NHS' outlined in the Better Health, Better Care Action Plan is beginning to take shape. The shift from viewing patients as ‘service users' to ‘active partners' will have a profound effect on NHS policy and practice. There are significant concerns that statutory patient entitlements will create a culture of litigation and that legally enforceable healthcare standards will have huge implications for service providers. How will the implementation of such legislation be monitored, what form of sanctions will apply should it be breached and will this lead to resources being diverted from direct patient care? Health professionals are confronted with an increasingly diverse range of ethical dilemmas throughout their careers. An increased emphasis on patient rights and public involvement in the NHS is likely to ensure such dilemmas become more common than ever and that ethical judgments - often made under the extreme pressures of limited time and resources - may become increasingly subject to legal review.

This conference will review the Government's proposals for developing a ‘mutual NHS'. It will explore the proposals outlined in the Patients' Rights Bill and the potential implications for service providers and will encourage discussions on a range of medico-moral dilemmas which test the boundaries of patient rights and involvement in healthcare delivery. If you have any queries regarding the conference or would like find out more information, please email mbellamy@mackayhannah.com

Medical issues in Euthanasia, and Suicide

The whole are of the management of the terminal phase of illness and the end of life is one in which medical practice is, of necessity, deeply involved. the manner in which the patient dies, whether in acute illness or in longer term chronic illness, may even be something of a touchstone for the quality of medical care. Since the dawn of the profession, doctors have been involved in dying; relieving its distresses, seeking to support tha patient in the process, whether long or short.

Acceptance of Death One of the most difficult disciplines for the physician or surgeon is to come to terms with the ultimate failure of all the therapeutic measures available to them and with which they have practiced. Death may be posponed, even avoided, but not ultimately evaded. If it is difficult for the doctor to countenance death, seeing it as the ultimate failure of art and skill, it would be even more difficult for the doctor to see him or herself as the personal agent of that failure. The wise and experienced doctor will certainly seek to use the skills of medicine to alleviate the pains and distresses of death, and indeed to make the process of dying as free of distress as possible for the terminally ill person.

Suicide
Suicide, although not an offence in law, is perceived among the most negative of emergencies to be handled in the casulaty and intensive care areas of general hospitals and, while compassion and understanding are readily extended to the unsuccessful victim, that sympathy and understanding are directed towards the person, rather than towards the act. The suicide of a patient who has been under regular care, whether terminally ill, psychiatrically depressed or in severe distress for other reasons, is a particular trauma to most health care professionals who may carry, in addition to the sense of failure when the patient dies, an equally distressing feeling that in some way they have failed that person while they were still alive and still amenable to supportive help.

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Suicide: the taking of one's own life

While no change has occured in the definition of suicide, it would appear that public condemnation of suicide as an act is less than in previous times. Suicide is still recognised by most people as a tragedy but not a sin. This may be related to change in the personal view of life and death and of one's responsibility for life associated with a widespread rejection of Christian views and values. Even prior to 1961, when suicide ceased to be a crime in Enmgland, suicide was not criminal in Scotland. The position of the Church of Scotland on suicide remains clear. It offers compassion and understanding rather than condemnation.

Non Voluntary Euthanasia

Non voluntary Euthanasia is ending the life of a person who lacks the capacity either to know or express his or her own wishes as to continued existence. Such a situation would arise in infants; in patients with severe brain damage or dementia; in severly mentally impaired people; and in people in a persistant vegetative state. The distinction between 'involuntary' and 'non-voluntary' is more than academic since the person in the former case would be capable of making a decision if given the opportunity. It is particularly important to bear in mind the situation of infants and children in terminal or severe illness and handicap.

Much of the debate concerning euthanasia revolves around adults, notably the elderly and the younger adult with progressive illness, but the problems may arise just as acutely at the earlier stages of life. the law is, in fact, the same for every age.

Koelzer and Brittingham: The Ethics & standards of Euthanasia and Palliative Care

Viktor Koelzer and Sara Brittingham have presented an excellent overview of the ethics and standards of euthanasia and palliative care

This is an article recently published on The Lancet Student. The authors review research that shows that there is alot of insecurity and misinformation in the provision of end-of-life care amongst medical staff. As the authors are medical students themselves they speak with knowledge about the need to have more information about end-of-life issues in order to develop their skills and confidence on dealing with terminally ill patients. The authors then go on to review the historical, ethical and leval aspects of palliative care and voluntary euthanasia in Europe. They reiterate their emphasis on compassion and respect in the provision of end-of-life care whilest respecting and adhering to the law and the ethical principles of our society. Koelzer and Brittingham then proceed to compare and contrast palliative care approaches with voluntary euthanasia approaches. They authors present contrasting approaches to addressing issues such as pain management, patient autonomy, spiritual support and communication.

Both voluntary euthanasia and palliative care options currently co-exit in Europe. It is clear that each country within the EU is addressing this issue in relation to its cultural and ethical framework, however, what seems clear if that some elements such as the Hippocratic oath and a common Judeo-Christian perspective are prevalent within the palliative care approaches in Europe. The authors state their view as follows

..."In the early stages of medicine, hardly any disease could be cured; instead, the patients were accompanied and comforted, trying to palliate suffering (10). One of the earliest medical codices, the Hippocratic Oath (400 B.C.), stated that doctors must never “give deadly medicine to anyone if asked nor suggest any such counsel”. This definite statement leads us to assume that disagreements about medically assisted death were already a matter of debate during this time. With the rise of Christianity in Europe, arguments against VE were further based on religious beliefs. Thomas Aquinas(approx. 1225-1274), one of the most important Catholic scholars of the middle ages stated in his main work “Summa Theologiae” that not only killing but also suicide was a capital sin, and emphasized the Christian virtues of “caritas” (Lat. benevolence) and “misericordia” (Lat. mercy) in the care of patients. In our opinion these values are still central in palliatice care today, emphasizing the Christian roots of the palliative care movement.

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This is thoughtful article for anyone interested in this debate.

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Different kinds of euthanasia? Some Definitions

The last post mentioned the need to examine the language that we are using to refer to end of life issues and in particular euthanasia. The different forms of euthanasia are futher explored in the following article from the BBC.

Active Euthanasia is doing something, such as giving a drug with the intention to bring about death.

Passive Euthanasia is the deliberate shortening of life through an omission to act. The term "passive euthanasia" is applied quite inapprorpiately to treatment withdrawal, where the treatment concerned is proving ineffective in achieving recovery and should rightly be stopped. Neither the withdrawal of inappropriate treatment nor the decision to refrain from using it can correctly be called euthanasia. These decisions are the expression of good clinical judgement.

A failure by a doctor to provide a patient with treatment thought by responsible medical opinion to be necessary in the circumstances, could well be a criminal omission, whereas at the other end of the scale, no doctor need resport to 'heroic methods' to prolong life.

Voluntary Euthanasia: is ending the person's life at their specific request. this category has been at the centre of attempts to legalise euthanasia. The 'specific request' is currently interpreted by supporters of the procedure, not only as a request at the time of the distressing illness, but also in advance, for instance by means of a Living Will.
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CreditsThe picture of the lfying bird was done by Kashyap-HC

Changes in the Language of Dying: some definitions

The original definition of euthanasia derived from two Greek words, eu thanatos -'dying well' or 'good death'. This concept of an easy or good death is one in which the relief of symptoms is sufficient to allow the patient to continue normal relationships and cognitive thought right to the immediate pre-terminal phase of life, without the intrusion of pain or other distress. This original meaning has changed.

Today, euthanasia means deliberately terminating the life of another person by an act or omission in the context of terminal, painful or distressing illness. Mercy-Killing is also used, defining motivation as much as action. In the context of the euthanasia debate it is interesting that groups seeking the introduction of voluntary euthanasia and assisted suicide tend to use language which conceals the lethal nature of the acts proposed. One no longer commits suicide- one performas 'self-deliverance'. A physician under a "right to die" law would no longer gie a lethal injection, he would administer an "aid in dying measure" This quote is an excerpt from na book by Joni Eareckson Tada entitled When it is right to die?

We shall be exploring in the next few post different words and meanings within the end-of-life debate.



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Credits
The picture of the floating feather was taken by Lutz-R Frank