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.

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.

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.”

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.

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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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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