Ian Galloway calls for the debate to widen

Ian Galloway, the Convener of the Church and Society council has called for a widening of the debate on assisted suicide to include issues of palliative care. This is in response to the fact that the Assisted Suicide Scotland Bill failed to reach the required vote at the Scottish Parliament. Margo MacDonald, the proponent of the bill, agreed with Mr. Galloway that the debate mucst also include the provision for palliative care.

What do we mean by "Quality of Life"

This is a very powerful video about a person with a genetical disorder. It has really made me think about the meaning of the concept "quality of life". Please watch it.

http://www.kierandodds.com/#/selected/end-of-life

Church of Scotland's position on the proposed End of Life Assistance Bill.

The Church of Scotland today urged MSPs to reject the proposed Lend of Life Assistance (Scotland) Bill, to be debated in the Scottish Parliament on Thursday 25th November.

Rev Ian Galloway, Convener of the Church and Society Council of the Kirk drew the attention of MSPs to the Committee which has undertaken intense scrutiny of this proposed legislation. He said: “The conclusions of the Committee are unequivocal: no change of the law in this regard is either required or desirable, as they say in their report that “the Committee was not persuaded that the case had been made …and, accordingly, does not recommend the general principles of the Bill to the Parliament.”

The ELA Scotland Bill proposes that, under certain circumstances, assistance to end their lives should be allowed for those who wish to. The Church argues that any legislation which endorses the deliberate ending of a human life undermines us as a society. The worth and dignity of every human life needs to be emphasised and celebrated; in particular, the deliberate ending of life would be a matter to be deplored if person was perceived (or perceived themselves) as merely a burden.

Legislation of the type proposed in the End of Life Assistance (Scotland) Bill represents much more than simply a tinkering with the law. Breaching as it does the societal prohibition on the taking of human life, it carries implications for attitudes to many aspects of health and social care, not simply for the determined few who are pushing for change.

Rev Galloway continued: “An important aspect of our life as a society is in caring for the most vulnerable in society. While we are sympathetic towards the fears and desires of those who may be afraid of a painful death, what is proposed in this Bill is not the solution. Rather, there is a necessity to ensure that, as far as possible, all have access to good palliative care, which, in the widest sense, involves caring not just for the physical but also the emotional and the physical and spiritual needs of people coming towards the end of their lives.”

Scots End-of-life Bill could lead to 1,000 deaths a year

Scots End of-life Bill could lead to 1,000 deaths a year. These are really stark projections of people presumably willing to commit suicide per year in Scotland. Palliative care nurses are also warning that if passed, this legislation would bring into Scotland, people willing to end their lives, pretty much in the same way as people travel to Switzerland. Cristina Odone, from the Centre for Policy Studies, has recently published a report starting that this legislation would make elderly and frail people extremely vulnerable to succomb to pressures for assited suicide. If life is considered expendible, because some people cannot contribute on economical and social terms to society, and there is a lgeal way of ending such lives, there might always be the temptation to view suicide as a normal way out. However, this position is not acceptable within a Christian outlook on life, that values everyone's contribution to society and that considers life sacred.

Fresh hope for severely brain damaged patients

Thanks to functional magnetic resonance imaging (fMRI) Dr. Owen a neuro-scientist from Cambridge University has been able to communicate with a patient who had been previously considered to be in a vegetative state. Although the equipment is not portable and cannot be used for frequent communication it seems that even when people seem to be locked into vegetative states, it is possible through suitable technology to communicate with them. This opens up again fresh avenues of research into what is meant by "quality of life". Surely if a person can communicate, even through a machine, we can no longer state that the person is in a "vegetative state". Read more about this by following the link Fresh hope for severely brain damaged patients.

Protests outside the Scottish Parliament

Protesters against the proposed end -of -life bill gathered aoutside the Scottish Parliament. This protest was particularly poignant becuase  it was organised by dissabled people who see the proposed bill as eroding their right to life. This was taking place as debates within parliament were addressing the same issues. It was wonderful to witness the agency with which individulas irrespective of their dissability were fully engaged in exercising their civic rights.  For a short film about the protest, please follow this link.

Does the proposed End of Life Bill have real support?

The assisted suicide bill has received the support of a humanist group however as noted in the article published by the Christian Institute in the following link, Scots end-of-life Bill backed by humanists the data presented support the claim that the majority of people in Scotland do not support the end of life bill. "Care not Killing" delivered over 14,000 postcards against the proposed Bill and only in July, Holyrood released data of a poll that showed that the majority of those in the study did not approve the proposed Bill. Allegations of support might be branded back and forth, but, the postcards and the polls are evidence of involvement against the proposed Bill.

Euthanasia and Assisted Suicide

John Wyatt has recently written a very good article on euthanasia and assisted suicied in the Cambridge Papers: towards a Biblical Mind collection. The paper argues that the arguments in favour of assisted suicide are no longer centred on unbearable suffering or pain. Instead proposers of assisted suicide and euthanasia, are stressing now the important of choice and control over the time and manner of death. This is coupled says Wyatt with "fears about the sociala dn economic consequences of increasing numbers of elderly and dependent individuals". Read the full abstract and access to the paper following this link.

Resources on End of Life Issues

The UK Clinical Ethics Network provides extremely useful information on the current frameworks available to make ethical decisions concerning end of life issues. Their website links to national policy and guidelines on end of life as well as providing links to a number of medical guidelines approved by medical professional bodies on end of life issues. this website is a useful resource.

When is medical treatment too much treatment?

I thought the following article was interesting. It argues that in the USA the medical industry prolongs life with expensive sometimes "unecessary" treatments. It proposes that time spent in peace within a palliative care environment is a better way of approching the end of life than through the continuouse struggle against death. I wonder if as a society we are able to move away from the culture of the beautiful and healthy, and accept that aging, and dying is the full completion of the cycle of life. Happy reading. Please post comments if so inclined.

Personal View of the Debate on the End of Life Assistance (Scotland) Bill

We are very fortunate to have the personal input of Rev Dr Donald M MacDonald. He is a medically trained minister of the Free Church of Scotland with twenty one years’ experience as a doctor and surgeon in Scotland and India before becoming the minister of a congregation in Scotland and then lecturing in Practical Theology in the Free Church College, Edinburgh. He retired in June 2009. He has had MS for 27 years and uses a wheelchair. His perspective therefore is of extreme importance for us and we are very grateful for his contribution.



On Saturday 12th June I attended a debate on the End of Life Assistance (Scotland) Bill in Committee Room 1 at the Scottish Parliament. Speaking for the Bill was Margo MacDonald MSP, supported by members of FATE (Friends at the End) and others, and against was Suselle Boffey, supported by members of Inclusion Scotland and others, many of whom have disabilities. The debate was ably chaired by Rev Cllr. Ewan Aitken. No vote was taken.

Margo MacDonald argued for the Bill on the basis of individual human autonomy: each one has the right to decide when one’s life is no longer worth living because of unbearable pain, weakness, or loss of independence and dignity. People should have the legal right to be helped to end their lives when they find life intolerable. She claimed that the majority of people are in favour of such a Bill, that similar legislation in the Netherlands and Oregon is working well and that her Bill has strong safeguards against abuse.

Suselle Boffey argued for the right of people with disabilities to have all necessary support to live independently to the very end of natural life. The Bill is harmful to the interests of disabled people because it includes as eligible for “end of life assistance” those who are “permanently physically incapacitated to such an extent as not to be able to live independently and who find life intolerable.” This potentially includes many thousands of people, especially those who do not have access to the support they need for independent living. The important thing is to ensure that disabled people are treated equally under the law and that this support is available. The Bill would encourage stereotypical views of disabled people as not having a good quality of life and would put pressure on them to think of themselves as burdens on society.

People were then invited to speak briefly from the floor. The views polarised between supporters of the Bill, who appeared to think it was self-evident to any rational person that it was humane to help someone to end their life when they found it intolerable because of pain, loss of independence and loss of dignity, and its opponents, who argued passionately that people with disabilities do have a good quality of life provided they have the necessary support and equipment to live with freedom, choice, comfort and dignity.

My own view
I oppose the Bill on the following grounds:
1. The Bill attacks the sanctity of human life.
From the Christian perspective human beings are made in God’s image and likeness, and this likeness and consequent dignity is not diminished by injury, illness, physical or mental impairment or loss of function. Defence of and care for the weak and vulnerable has always been a cornerstone of the Christian social conscience. We have a duty to care for one another to the very end of life and it is wrong to deliberately end someone’s life.

2. The Bill is based on the myth of absolute individual autonomy.
The foundation of the Bill is clearly stated on page 2 of the original Consultation Document to be “the principle of autonomy, that the person has the right to determine the quality of his or her own life and its value, unrestricted by the moral, cultural, religious, or personal beliefs of others”. This would appear to give the individual an absolute right to decide when his/her life has such a quality and value that it should be ended. This extreme individualism ignores the importance of the fact that we humans exist in relationships and in community. We come into the world as completely dependent creatures and we remain dependent on one another to a greater or lesser extent throughout our lives. As well as rights we have responsibilities and duties towards others. The care we exercise towards one another is part of what makes us fully human. We should also learn to receive care as well as give it. It should not be regarded as loss of dignity to be dependent on others. I have found that becoming more dependent on others makes me more appreciative of the loving care and the sheer humanity of those who care for the weak, the vulnerable and the defenceless. We have no right to demand that someone help to end our life. Ending an innocent person’s life, even with the purpose of reducing the amount and length of suffering is not justified, especially when good long term support and palliative care are possible. Our common humanity is best represented and supported by ensuring that this kind of care is available to all and not by deliberately ending a life. I fear that this Bill, if it comes into force, would lessen people’s willingness to care sacrificially for those who have long term disabilities and those suffering from chronic, debilitating and terminal illnesses.

3. The Bill proposes an unacceptable change in the role of medical practitioners.
From the time of Hippocrates, 2,400 years ago, it has been the accepted ethical standard of the medical profession not to administer a fatal dose to a patient. This radical new proposal would have serious effects on the profession and the doctor/patient relationship. It would require doctors to be trained in “end of life assistance” – in other words how to kill people. It would cause a division in the medical profession between those who see deliberately ending a patient’s life as acceptable and the vast majority who want to maintain life with all the support necessary to reduce the suffering of those who are dying. It would undermine confidence in the medical profession as supporters of life. Of course the time does come in the course of an illness when death has to be allowed to supervene, but supportive and palliative care should continue to the end and the doctor should never intentionally bring about the death of a patient. Patient autonomy is not absolute. The patient has the right to refuse treatment that he/she considers to be intrusive and distressing and may prolong life only at the cost of increased suffering, but this does not confer the right to demand that the doctor end their life deliberately. The two situations are different.

4. The Bill is poorly drafted and, despite so-called safeguards, wide open to abuse.
I have highlighted many defects in my submission to the Parliamentary Committee, but here are a few of the most glaring:

4.1 End of Life Assistance is defined as “assistance, including the provision or administration of appropriate means, to enable a person to die with dignity and a minimum of distress”. The title of the Bill says that it is for “persons who wish their lives to be ended”, obviously by someone else (euthanasia) and not necessarily by themselves (assisted suicide). “Appropriate means” are never defined, another serious omission. The inference of the title and the definition taken together is that only by deliberately ending one’s life can one die with dignity – an insult to those practising and those benefitting from palliative care. At a time when we are trying to stem the tide of suicides among young people who see no point in going on living, this seems a strange note to be sounded in proposed legislation!

4.2 The Bill defines too loosely the categories of people eligible for “end of life assistance”. “Terminally ill” is defined as having less than six months’ life expectancy. This is extremely difficult to predict. As noted above, the inclusion of a large number of people who are “permanently physically incapacitated” is unacceptable. The main criterion of eligibility seems to be finding life “intolerable”. This is a subjective judgement and may well vary over time depending on a wide range of factors – physical, psychological, emotional and social.

4.3 There are many flaws in the procedure of application for “end of life assistance”. It lays a huge burden of responsibility on the “designated practitioner”. The role of the psychiatrist is fairly peripheral, being limited to judging capacity and freedom from undue influence. The possibility of palliative care has only to be “discussed”; the minimum age is only sixteen; the residency requirements could easily be evaded; the various time limits are too short; the requirements for witnesses are poorly defined and the impression is given of these being merely token safeguards.

4.4 The procedure at the end of life, including the means of ending life and who actually administers them, is not clearly defined. There seems to be a deliberate vagueness about the matter, with the liberal use of euphemisms.

4.5 Although the motive of the framers of the Bill is not to save money, the accompanying Memorandum notes that this Bill could actually result in savings for Health Boards, because ending a person’s life is cheaper than continuing to treat and care for the person (paragraph 97). This potential financial saving could very quickly become a determining factor in decision making in treating people with disabilities or chronic illnesses and in end of life situations and this would put extra pressure on patients and carers.

I believe that if this Bill were to become law, it would have a detrimental effect on society’s respect for human life, would damage the doctor-patient relationship, would be difficult to enforce without widespread abuse and would lead to a devaluing of the lives of people who are dependent on others because of disability or chronic illness or are nearing the end of life. Evidence from the Netherlands and the State of Oregon shows the potential for abuse of such legislation. Instead of such a law what we need is to ensure the widest possible availability of support for independent living and good long term and palliative care for all who need them.

Moral Arguments for and against Assisted Suicide

The British Medical Association, BMA published some time ago a discussion paper on the moral arguments for and against assisted suicide. The argumentation is interesting and can help anyone to make up their minds on this difficult issue. The discussion paper is available here.

Nurses to express their views on end of life issues

Nursing Times has developed an online questionnaire asking nurses about their feelings and experience around assisted suicide. the purpose is to gain a comprehensive picture of how nurses deal with this difficult issue in hospitals, in the community, in hospices and nursing homes. The survey is anonymous and the full results will be reported in an issue of Nursing Times and on www.nursingtimes.net soon.

If you are a nurse, please fill in the questionnaire and express your views on this important subject. It is crucial to have all medics on the front line od this difficult subject express their opinions.

The End of Life Assistance (Scotland) Bill: Views from the trenches. Part 4

This posting is the fourth and final part of the article that Dr Stephen Hutchison MD FRCP(Glasg, Consultant Physician in Palliative Medicine at the Highland Hospice has written on the End of Life Assistance (Scotland) Bill.

The doctor is also responsible for determining at any stage in the process, including during the final act, whether any comment ‘however informal’ by the person indicates a wish to stop the process. How does a doctor qualitatively evaluate statements or questions in this context? For instance, do expressions of hesitation or doubt, or concerns about the family, constitute informal revocation? Can any assurance be given that where hesitation is expressed to someone else that this is passed on to the doctor, rather than suppressed with well meaning or malicious intent? In the context of the decision in hand, how can a doctor determine with the required confidence what would and what would not amount to an informal revocation. So not only is this a vague ‘safeguard’ it actually prejudices the care of anybody going through the process, because it inhibits open dialogue with the doctor which is so important when approaching death.

So, as always, there are two sides to the argument. Although there are some strident campaigners, for the most part those on each side approach the issue with compassion at heart and we should acknowledge that. If you favour this legislation, you have to address its inadequacies. And if you oppose it, you have to recognise that you are left with very difficult questions about personal choice and suffering. Let’s avoid arrogant, polarised, gut reactions. Alienating the opposition makes good journalese but doesn’t encourage informed, intelligent debate. Our politicians are exercised by this issue and public ranting doesn’t help them. They have a free vote when it comes to parliamentary debate. We always tend to think that they have a responsibility to us, but forget our responsibility as constituents to let them know what we think. Why not write to your MSPs and give them some constructive thoughts about this issue?

The End of Life Assistance (Scotland) Bill: Views from the trenches. Part 3

This posting is the third part of the article that Dr Stephen Hutchison MD FRCP(Glasg, Consultant Physician in Palliative Medicine at the Highland Hospice has written on the End of Life Assistance (Scotland) Bill. The article will be posted in 4 parts to facilitate reading.

The House of Lords Select Committee made several recommendations to guide the drafting of legislation about assisted dying. It would have been wise to have accommodated these when drafting the present Bill, but unfortunately they have been largely disregarded. The Bill does not draw a clear distinction between assisted suicide and voluntary euthanasia or set out clearly the actions which a doctor may and may not take in either case. There is no guidance whatsoever on what a doctor may or may not do, or agree to, in bringing about the person’s death. It does not adequately address the need to identify psychological or psychiatric disorders. Whilst the wording regarding prognosis in terminal disease is an improvement on previous legislative attempts, the Bill does not acknowledge the everyday clinical realities of prognostic inaccuracy. It does not focus on unrelievable suffering, but only on intolerability. In making provision only for discussion of palliative care, the Bill does not require patients to experience such care before taking a final decision. And finally it makes no allowance for conscientious opt-out for doctors.
I mentioned safeguards. The Bill requires a staged formal process, with stipulated discussions at each to determine that the person knows exactly what they are asking for, is aware of the alternatives and that they can stop the process at any time. Two psychiatric assessments are required, but it is permissible for both to be conducted by the same person, who is only required to report that the patient is acting voluntarily and with capacity, and not on how appropriate it is to continue with the process. The decision as to whether the process should be carried through rests solely with the designated practitioner. Approval of the second request must be by the same doctor who approves the first. It is a stretch of the imagination to construe this as an independent second opinion! The doctor is expected to ensure, at several points in the whole process, that the patient is not acting under undue influence. There is no indication as to how this should be determined, or of what amounts to undue influence. Is it enough to ask the requesting person? Will that also require a formal statement? The witnesses also have to attest that the requesting person has not come under undue influence. Yet again there is no indication as to how this should be determined. What enquiry are the witnesses required to undertake? How would reliability be assured? What happens where there is a conflict of opinion amongst all these people about the influence? It is impossible to ascertain undue influence, because the influences under which we function are many and varied, internal and external, and can be very subtle. Doctors are used to dealing with uncertainties. Clinical judgments are not always binary – yes or no. But when the outcome is deliberate action to end a human life, the opposite principle to that under which doctors currently work, uncertainty cannot be entertained.

The End of Life Assistance (Scotland) Bill: Views from the trenches. Part 2

This posting is the second part of the article that Dr Stephen Hutchison MD FRCP(Glasg, Consultant Physician in Palliative Medicine at the Highland Hospice has written on the End of Life Assistance (Scotland) Bill. The article will be posted in 4 parts to facilitate reading.

Dignity in health care has come to be synonymous with assisted dying. The Voluntary Euthanasia Society is now called Dignity in Dying, and if you go to Zurich to end your life, it is to the Dignitas organisation. All political attempts to legalise assisted dying base their case on dignity. The MacDonald Bill, as you can see, does the same, but doesn’t define dignity, or explain why it should be enhanced by the Bill.

Dignity is a complex social construct, involving honour and esteem, merit, grace, relationship and dependence, who we are and how we behave. There are ways of identifying factors which compromise dignity in health care and good evidence on how to enhance it. Dignity is cheapened by simply equating it to assisted dying. Arguably the MacDonald Bill diminishes dignity in dying because of the requirement to submit to a formal protocol, with numerous consultations, scrutiny of one’s mental health, within a short time frame and without the opportunity to discuss hesitation or distress lest that should be interpreted as a wish to stop the process, all at a time when life is already deemed to be intolerable!
So what about choice and autonomy? Isn’t autonomy a basic human attribute? Dictionary definitions of autonomy include; ‘Freedom to determine one’s own actions; to govern our will by our own principles and laws; to make choices regardless of the influence of, or effect upon others’. Proponents of assisted dying say that we should be free to make our own choices about these deeply personal issues, without having to defer to anybody else. But if we think about it a bit, is there anything we can do or decide, trivial or important, which does not have a potential or actual effect on others? In reality, is autonomy not a limited concept? Maybe it is actually a myth! We are in fact created and designed to be relational and interdependent and our very dignity is intrinsic to that. Choice is something we do have, but we must choose responsibly.

Margo MacDonald’s Bill recognises that people can come under inappropriate influence, and it describes safeguards to prevent this. Scrutiny of the safeguards reveals inadequacies, but that is not the point I want to make here. What I want to say is that when people are seriously ill or incapacitated, they are particularly vulnerable to internal and external influences. The availability of the choice for some to have their lives ended would create a powerful societal influence which would place others – a greater number of people - at risk. Exposure in the course of debilitating and terminal illness to the very influences created by this Bill would increase the risk to a vulnerable majority. One individual insisting on the right to die will affect others. When people say that life and death are individual matters, they are wrong.

What does the Bill propose? To summarise, if it should become law in its present form, it would be legal, under certain circumstances, to assist a requesting person to die, or to help someone else to assist the person to die. It is usually assumed that such a procedure would be carried out by a doctor, but this Bill makes allowance for this to be done by lay people who meet certain eligibility criteria, and provided a doctor is present. The requesting person must be at least 16 years old, with either a terminal illness with a life expectancy of six months or less, or a physical debility which renders them unable to live independently, plus they must find life to be intolerable. The formal procedure includes two independently witnessed written requests by the person, assessments by the doctor to whom the request is made, assessments by psychiatrists, discussion with the doctors about the illness or disability from which the person suffers, feasible alternatives to assisted dying, the means of causing the person’s death, who should do it, where it should be done, and the option to stop the process at any time.

Given that the doctor is the only professional mentioned in the Bill and related documentation, it is reasonable to assume that the doctor will be responsible, not only for clinical assessment and drug administration (assuming that to be the chosen means of ending life), adjudication of the degree of dependence caused by a disability and the level of intolerability of life arising from this or from a terminal illness but also for scrutinising the credentials of the witnesses, and determining that the eligibility criteria of witnesses are met. The Bill is completely silent on the means by which death is to be brought about, as this is left to the supposed expertise of doctors. There is no opt out for doctors who conscientiously object to assisted dying, and referral to a willing colleague is obligatory. It is therefore possible that the requesting person could end up being assessed by a doctor who does not know them, and who would certainly have some difficulty assessing the degree of intolerability, and the level of influence under which the person is acting, let alone the legal ins and outs. And as far as the legal side of things is concerned, it is interesting to reflect on the comments of Julia Cumberlege, former health minister, House of Lords, who said; “The medical profession is there to treat, cure, and care for sick and disabled people. Once lawyers get involved the whole premise changes: bitterness, strife, and serious money take over, families are divided, and suspicion reigns. Doctors should steer clear of assisted suicide—or more accurately of putting people to death—if they want to retain the trust of their patients.” This Bill depends largely on the cooperation of doctors to make it work, but there has been no prior focussed consultation with the medical profession. Moreover there doesn’t seem to have been any thought about the level of competence a doctor would need before providing this service, how doctors will be trained for that, or about personal and professional support for those who are willing to be involved. Nor have similar needs for lay people been considered.

Continued on next posting...

The End of Life Assistance (Scotland) Bill: Views from the trenches.Part 1.

We are very fortunate to be able to publish an article that Dr Stephen Hutchison MD FRCP(Glasg, Consultant Physician in Palliative Medicine at the Highland Hospice has written on the End of Life Assistance (Scotland) Bill. The article will be posted in 4 parts to facilitate reading.

Some people because of actual or anticipated physical or existential suffering will wish to end their lives, and sometimes people with serious and incapacitating illnesses do not receive an adequate standard of care. However, it is justified to conclude from this that we need the facility of legalised assisted dying?

Most of us have strong opinions about this. We tend to adopt deeply entrenched positions, shouting from one side about suffering, choice, autonomy and rights, and replying from the other with a sort of “Thus saith the Lord: Thou shalt not kill, and nothing more need be said” approach. Maybe it is difficult to find a middle ground here, and I suppose I am in my trench too, but it is important to appreciate the view from the other trench, so that this complex issue gets more than the knee-jerk response we usually hear. We need to avoid knee jerk responses ourselves – it isn’t just others who are guilty of that.

Most of us hope to avoid severe suffering, and in that event, the option for life to be ended humanely has appeal. Many doctors, including me, facing terminal care situations where treatment is not providing sufficient relief will have been attracted by the idea of being able to gently end life and bringing release. Sometimes the distress of life’s circumstances is beyond anything that a doctor can address. One of the fundamental things about being human is that we have choice. Choice, autonomy and dignity are buzz words nowadays. When presented on the one hand with unbearable pain, loss of control of bodily functions or dependence on others for basic care, and on the other hand to have the option for our lives ended with dignity, the choice seems obvious. How could anyone think that option was wrong? And can we not devise safe legislation to enable the inclusion of this ultimate act of compassion into medical care? These are difficult questions. Glib answers don’t convey much love and compassion, and the sort of right wing intolerant so-called Christian responses I sometimes hear on radio phone-ins are particularly irritating. For goodness sake let us recognise the real challenges around this issue, and Christians in particular should be avoiding un-Christ-like hard hearted responses.
We need to approach this issue compassionately, but also intelligently. One of the problems with public opinion is that people have not been well informed about what exactly such legislation would mean for patient care, and for society generally. The report of the House of Lords Select Committee, set up to comment on Lord Joffe’s recent attempts to introduce assisted dying, contains an extensive section about public opinion. It concludes that the issue of assisted dying is extremely complex, and that the real views of the public are obscured by inadequate information and appreciation of the implications of such law, for themselves and for society. Current public opinion, whilst generally in favour of assisted dying, is largely superficial and does not have sufficient rigour or quality to guide legislative change.

The policy Memorandum accompanying Margo MacDonald’s Bill mentions several distressing instances of suffering. They certainly should distress us. However, it is a matter of fact that people usually think they would like assisted dying to be available just in case they get severe pain, or other symptoms, in a terminal illness, rather than the actual experience of these. In other words it is fear of pain rather than actual pain which underlies the request. People experiencing terminal illness have a similar spread of opinion as the wider public. Of those who do express the wish for their lives to be ended, many have depression. Anecdotally, others change their minds once they have received good palliative care. So when I read about pain, distress and suffering in the Policy Memorandum, I wish I had more information about the level of care these patients received, and if it wasn’t good enough, I want to know why – because in the UK we have a magnificent standard of palliative care and that should have been available. We also need to be a bit careful about the assertions in the documentation that assisted dying goes on under cover anyway and it would be better to legalise and regulate it, and also that is compatible with palliative care. There is good evidence that doctors in the UK rarely engage in such practices, and if we look at the definitions of palliative care as well as the experience of palliative care practice in societies where assisted dying is legal, the claim that the two are compatible becomes less than convincing. The debate on assisted dying will inevitably be passionate, on both sides, but we need to be careful how we interpret evocative anecdotes about suffering, and not take everything at face value. We need to subject the information we are fed to careful scrutiny if we want to develop an intelligent opinion about this.

Margo MacDonald’s Bill declares its purpose as the “provision or administration of appropriate means to enable a person to die with dignity and a minimum of distress”. The wording sounds wholesome, and implies that the Bill makes provision for this. But provision for that is already made in health care, and palliative care in particular is directed to precisely these objectives. Opponents often say that we should call a spade a spade – this is killing and we should use that word. That may be true but it sort of implies a callous or murderous attitude, and whilst one of the undoubted dangers of such legislation is the potential for malicious motivation, compassion for the requesting person is likely to be the predominant influence. Maybe it would be more honest, to describe the purpose of the Bill as the legalisation of intentional ending of life.

.... Continued on next posting.

Choose Life Programme.

Suicide is one of the principal causes of death for young people in industrialized countries, including Scotland. An advertisement will be aired in prime time television highlighting the need for everyone to support individuals contemplating suicide. The ad mentions that help might be as close as your nearest cabbie or your hairdresser and goes on to propose that people from all walks of life can be trained in providing help to potentially suicidal people. The ad is part of the Scottish Government’s Choose Life Programme, which is a 10 year plan aimed at reducing suicides in Scotland by 20% by 2013.
Rev. Ian Galloway, Convener of the church and Society Council mentioned in his blog that suicide is everyon'es business and that the Choose Life programme with its emphasis on early intervention and provision of initial help by trained members of the public was to be commended. It should be noted however, he continued, that there are many potential reasons for young people to become suicidal and that the advice of trained professionals and counselling staff carries the weight of evidence-based research.

The opinion polls on Assisted Suicide

Dr Calum MacKellar, Director of Research at the Scottish Council on Human Bioethics has written a letter to The Herald, explaining the danger that leading opinion polls can have in swaying public opinion in Scotland in favour of the assisted suicide bill proposed by Margo MacDonald. According to Dr. MacKellar, the results of the polls are contradictory and do not consitute a basis for ammendment of legislation. Follow this link to read the full letter.

The Royal Dutch Medical Association against Assisted Suicide Amendment

The Royal Dutch Medical Association has expressed its reservation over the proposed amendement to current legislation on assisted suicide in The Netherlands. A campaign group claims to have collected enough signatures to force the proposal to be discussed in parliament. The proposal consists of "training non-doctors to administer a lethal potion to people over the age of 70 who "consider their lives complete" and want to die. The assistants would need to be certified and make sure that patients were not acting on a whim or due to a temporary depression, but from a heartfelt and enduring desire to die".
Currently, two medical doctors need to certify that a patient is suffering unbearably and has no hope of recovery before a lethal injection can be applied. The Royal Medical Association feels that the proposed amendment would reduce the direct involvement of medical doctors on the decision-making processes and has therefore expressed its reservations.

Statistics on Assisted Suicide

Simon Rogers from the Guardian has published statistics on the number of people that have carried out assisted suicide in a notable clinic in Switzerland. According to the data, since 1998, more UK citizens have used the clinic than Swiss nationals. Overall,German nationals are the most frequent users of the clinic. It would be interesting to reseearch the reasons behind this heavy use and whether they are tied in to provision of palliative care facilities.

According to the EAPC Task Force on the Development of Palliative Care in Europe, in 2006,

There is no national data about the palliative care workforce in Germany. It is estimated, however, that each palliative care unit has at least one full-time physician who is trained in palliative care. Inpatient hospices usually have no in-house doctor but work together with local GPs, of whom an increasing number have participated in a palliative care training course

.

Summary of the DPP Guidelines

The following summary of the DPP Guildes was provided by Care not Killing.

DPP REVISED PROSECUTION GUIDELINES

These guidelines are a considerable improvement over the interim version because:

- They no longer suggest that a more lenient view will be taken of assisting the suicide of sick or disabled people than of assisting the suicide of others;

- They no longer give special protection to spouses and family members as assisters of suicide.

- They also make clear that assistance given by a doctor or nurse to a patient under their care would be regarded as an aggravating factor.

These are all very important and welcomed changes.

The new guidelines also make clear that the law has not changed and that anyone who assists a suicide must expect to be prosecuted unless there are clear and compelling reasons to suggest otherwise. The guidelines will give no immunity from prosecution. We welcome this reaffirmation.

Everything depends on how the CPS operates the guidelines in practice. There must be transparency over prosecution decisions. We will be watching carefully to monitor practice.

Other Messages

On the concept of publishing prosecution guidelines:

The remit given to the DPP by the Law Lords - that he should make clear his prosecution policy for assisted suicide - is inherently unsound. To tell us how far we can go in breaking the criminal law without being prosecuted risks encouraging law-breaking up to the limits suggested. It poses very real dangers to public safety.

The CPS does not tell us how much we can steal before being charged with theft or how much injury we can inflict without being charged with assault. Assisted suicide should be treated in the same way.


On the revised guidelines generally:

The law has not changed. Assisting another person’s suicide remains a criminal offence.

We are pleased to see that the DPP has emphasised that nothing in these guidelines should be interpreted as implying that a prosecution will not take place if certain boxes are ticked. Anyone minded to assist another person’s suicide should pay heed to that before embarking on such a course of action. We are also pleased to see that the DPP has emphasised that a prosecution can be expected to take place unless there are clear and compelling circumstances to suggest that that should not happen.

Recent prosecutions (eg the Gilderdale case) have shown that the Crown Prosecution Service will not hesitate to prosecute where necessary.


On the revised guidelines more specifically:

The DPP has taken on board many of the concerns that we expressed in relation to his interim guidelines. The revised guidelines are not perfect – for example, it is not clear how it is to be established that a suspect was “motivated wholly by compassion” . But they are a considerable improvement on what went before. Much will depend on how the new guidelines are put into practice. There needs to be complete transparency of prosecution decisions if public confidence is to be maintained that vulnerable people are not being put at risk.

Should you wish to see the full documentation available on the CPS website:
1. DPP Final Guidelines: Please follow this link.
2. Detailed summary of responses to the consultation: Please follow this link.
3. The Code for crown prosecutors: Please follow this link.

Snapshot on Public Opinion on Assisted Suicide

Keir Stamer, QC Director of Public Prosecution published a policy on assisted suicide on the 25th of February. Nearly 5000 responses were received by the Crown Prosecution Service following a consultation started in September. The report on the consultation exercise is available here. In the words of Mr. Stamer, "The policy is now more focused on the motivation of the suspect rather than the characteristics of the victim. The policy does not change the law on assisted suicide. It does not open the door for euthanasia. It does not override the will of Parliament. What it does is to provide a clear framework for prosecutors to decide which cases should proceed to court and which should not". The full policy is available here.

Briefing paper on End of Life Assistance Bill

The Scottish Churches Parliamentary Office, SCPO has provided a very interesting briefing paper on the End of Life Assistance Bill. It provides wonderfully clear background reading on the Bill. Please follow this link to read the full text.

Is there a bias in BBC coverage about right to die?

The BBC has been accused of pushing the ‘right-to-die’ agenda by giving hours of airtime and leading news bulletins to the opinions of campaigners and publishing the results of opinion polls in a selective way. The BBC website has presented the views of celebrity fantasy fiction writer Terry Pratchett (last night’s Dimbleby lecture) and Mrs Kay Gilderdale (last night’s Panorama programme produced by Jeremy Vine) without giving similar space to opposing opinions.

If you care strongly that other views on this crucial issue be heard, please complain to the BBC about the bias of the coverage, and about the way that the views of disabled people in particular have been marginalised in a debate which affects them so personally. The complaints form can be accessed here.

Alternatively phone them on 03700 100 222 or write to BBC Complaints, PO Box 1922, Glasgow G2 3WT

Choosing Life, Choosing Death, book review

Dr. Murdo Macdonald, Policy Officer of the Science Religion and Technology Project, has sent us a link to to a book review that addresses important issues in our understanding of the reasons behind an educated choice against assited suicide. It’s a review of a book, “Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law” by Charles Foster. A couple of quotes from the review (I haven’t read the book itself...!)

"(Autonomy)… is commonly translated in the legal arena in positive terms of self-determinism and negative constraints of non-interference…..autonomy has arguably established itself as the dominant principle in medical ethics, operated above all else. This 'tyrannous' rule of autonomy is Foster's subject matter"

“Foster argues that autonomy, as a guiding principle, is at best unhelpful in determining a course of action (it lacks the prescriptive function the law so requires) and at worst leads to unsavoury conclusions.”

Care not Killing Campaign

A bid to block Members of the Scottish Parliament discussing a new law for assisted suicide in Scotland has been launched through the Care not Killing Campaign. The bill was put forward by MSPS Margo MacDonald and it is expected to come to Parliament in January. Please consult the Care Not Killing website in order to take action and support the campaign.