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