Printed from: https://archive.cmf.org.uk/advocacy/submissions/?id=33
Published: 4th April 2005
The Christian Medical Fellowship (CMF) is an interdenominational organisation with more than 4,500 members. We have over 450 Doctor and 110 student members in Scotland. The membership comprises British doctors who are Christians and who desire their professional and personal lives to be governed by the Christian faith as revealed in the Bible. Members practise in all branches of the profession, and through the International Christian Medical and Dental Association are linked with like-minded colleagues in over 100 other countries.
CMF regularly makes submissions on ethical matters to Government committees and submitted evidence to the 1993 Lords Select Committee on Medical Ethics. [1] We have also published widely on the subjects of euthanasia and assisted suicide (please see our website at www.cmf.org.uk and our CMF Files on Euthanasia [2] and Assisted Suicide [3]). We are grateful for this opportunity to comment on the difficult issues raised by the Paper and would be very willing to give oral evidence if invited.
We recognise the priority given to care at the end of life by the Scottish Executive and its commitment to providing equality of access to good palliative care. Examples would be initiatives such as improving support for Hospice and Specialist Palliative Care and Cancer and Palliative Care in Primary Care by implementation of Projects such as the current “Gold Standards Framework Scotland”.
Malcolm Chisholm, MSP, previous minister of health, speaking at the Scottish Partnership for Palliative Care AGM in November 2000 said “palliative care has been one of the drivers in developing the sort of services all patients expect and deserve: personalised, seamless, of the highest quality across the country as a whole.”
Our submission is divided into two sections. The first addresses our general concerns about the legalisation of assisted dying. The second addresses specific elements of the Paper. Our conclusion is that euthanasia and assisted suicide should not be legalised and that this bill should not proceed.
In the terms of the Consultation Paper assisted dying means the attending physician providing the means to end the patient's life.
The arguments against euthanasia and assisted suicide are essentially the same. We have therefore used the term 'assisted dying' to encompass both practices, and have outlined below our objections to the major arguments in their favour.
One of the major arguments in favour of assisted dying is that of autonomy, the so-called 'right to die'. We all value living in a free society but for society to function there must be limits on individual autonomy. Rights need protection, but must be balanced against responsibilities and the rights of others. No person chooses assisted dying in isolation. Friends, relatives, healthcare staff and society are affected by the wider ramifications of the process. The effects of individual decisions on others now living and on future generations must be considered. Autonomy is never as uncomplicated as 'my right to die'. Therefore although we recognise the importance of autonomy we have the following concerns in relation to this Consultation Paper.
1. The 'right to die' puts vulnerable patients at risk
The law is always concerned to protect vulnerable groups in our society. The Select Committee on Medical Ethics [4], in its 1994 report, unanimously ruled that there should be no change in the law. Lord Walton reflected on this in a speech to the House of Lords on 9 May 1994:
'We concluded that it was virtually impossible to ensure that all acts of euthanasia were truly voluntary and that any liberalisation of the law in the United Kingdom could not be abused. We were also concerned that vulnerable people - the elderly, lonely, sick or distressed - would feel pressure, whether real or imagined, to request early death.'
This conclusion still holds.
2. The 'right to die' over-simplifies the difficulties in decision-making
Many patients with a life-threatening illness are vulnerable and lack the knowledge and skills to alleviate their own distress. They may well be fearful about the future and anxious about the effect their illness is having on others. Their decision-making may also be affected by stress, depression, confusion, and dementia. There are many anecdotal accounts of patients who, at a time of crisis, say 'let me die', but are grateful that their request was not heeded.
Many elderly people already feel a burden to family, carers and a society which is cost conscious and short of resources. They may feel pressure, real or imagined, to request assisted dying. Baroness Finlay of Llandaff was quoted in Hansard [5] as saying 'A sense of a duty to die is all too easy to create and all too difficult to detect.'
All human beings are worthy of dignity and respect and should be cared for throughout their lives. People nearing the end of their lives need to know that we, as doctors and as a society, are committed to their well-being, even if this does involve expenditure of time and money. Assisted dying, as proposed risks abandoning the individual in their suffering, whether physical, psychological or spiritual.
In the 2002 study by Kelly et al[6] there is an acknowledgment that 'the wish to hasten death has been shown to be temporally unstable, raising concerns about assisting a patient's request for suicide at any particular point in their illness.' Poor communication, lack of emotional support from doctors and a concern that the patient was a burden to others were associated with a greater desire for a hastened death. Where these factors were absent there was a low likelihood of a patient expressing an interest in an accelerated death.
The desire for death is most significantly correlated with measures of depression in terminally ill patients.[7] Yet nearly 80% of psychological and psychiatric morbidity in patients with cancer goes unrecognised and untreated.[8] It is important that efforts are focussed on addressing these issues in patients. The debate about assisted dying must recognise the importance of psychiatric conditions - which are potentially treatable - and that a patient's desire to die will often decrease over time. While we recognise that certain mental stresses are not treatable – existential angst, loss of dignity, fear of the dying process – these factors are not medical as such, and do not warrant a 'medical' solution in the form of assisted dying. The spiritual and emotional nature of these issues may require the input of people from outside the medical profession. Doctors cannot be expected to be pastors and counsellors; they are not necessarily equipped to address the many needs behind a patients expressed wish to die. Allowing them to kill patients is not the answer to that problem.
3. The 'right to die' is the 'choice' mainly of those who are well not those who are terminally ill
In Emanuel et al [9] 60% of the terminally ill respondents supported euthanasia in a hypothetical situation involving others, but only 10% seriously considered euthanasia for themselves. Less than 4% had discussed these interventions with a physician or hoarded drugs for suicide and a very small minority of patients took concrete action such as requesting assistance to die. The paper concludes that patients' personal interest in assisted dying is not a stable preference but may shift over time.
Interest in assisted dying is far less in the terminally ill than in the general population (if surveys such as those by the Voluntary Euthanasia Society that cite 81% support for it amongst the public are to be believed [10]) and it cannot be assumed that a desire for assisted dying at one point in time will remain as death actually approaches.
4. The right to die of the few may open the door to a slippery slope that puts the vulnerable at risk
The 'slippery slope' is a contentious issue, but we believe a real one. Human nature seems such that it will push beyond what lawmakers originally intend. For example, those who framed the 1967 Abortion Act did not envisage the abortion on demand practices of the 21st century. Would a similar slippery slope follow the legalisation of assisted dying? There is no evidence to prove it would not. Without entering the philosophical debate, we are greatly concerned by aspects of the Dutch practice of euthanasia.
Philosophically it is hard to limit assisted dying to just those who are terminally ill. If relief of unbearable suffering is the aim then why not extend it to other patient groups who are suffering unbearably? To refuse assisted dying for patients who are not terminally ill but with similar symptoms could be seen as discriminatory. And why just limit it to patients who can request assisted dying? Surely it would be 'bad practice' and 'uncompassionate' to see someone suffering unbearably but not to offer them assisted dying because they were unable to request it themselves.
The Royal Dutch Medical Association (KNMG) and the Dutch Commission for the Acceptability of Life Terminating Action have recommended that active termination of the lives of patients suffering from dementia is morally acceptable under certain conditions. Two earlier reports from the commission affirmed the acceptability of similar action for severely handicapped neonates and comatose patients.[11,12] A study of Dutch neonatal doctors showed that just under half had assisted the death of a handicapped newborn child, despite this situation being outside the euthanasia legislation.[13] Case reports include a child killed for no other reason than it possessed abnormal genitalia and a woman killed at her own request for reasons of 'mental suffering'.[14]
Involuntary euthanasia will happen, regardless of the intentions of the legislators. According to the first “Report on Euthanasia and other End-of-Life Decisions in the Netherlands (Remmelink)”,[15] there were over 3,000 deaths from euthanasia in the Netherlands in 1990. More than 1,000 of these (0.8% of all deaths) were without an explicit request from the patient. The most recent figures in 2001 show that the problem persists.[16,17] A conservative estimate suggests more than 6,700 deaths due to “Ending Life Without Explicit Request”, since 1990.
Furthermore, there is evidence of continued poor compliance with reporting such events in both the Netherlands and Oregon. This is a major cause for concern and would invalidate the reliability of any monitoring commission that might be set up.[18]
5. The 'right to die' will change the role and vision of the medical profession
Legalisation of assisted dying will present legalised killing as a potential good rather than a fundamental harm for the first time. It will establish killing as a viable 'therapeutic option' that, if deemed valid in some cases, will need to be considered in all cases. This will fundamentally change the whole ethos of medicine. As a profession, and as a society, we have always seen the wish to die, for example in the suicidal person, as a cry for help, an indication that something is wrong that needs to be addressed. The medical profession has been built on seeking ways to relieve suffering, treat illness and preserve life; to restore dignity and hope. This bill changes the role of doctors and the doctor-patient relationship by introducing the option of doctors killing their patients.
Calls for assisted dying have been encouraged either by the failure of doctors to provide adequate symptom control, or by their provision of inappropriate interventions which neither lengthen life nor improve its quality. This has understandably provoked distrust of doctors by patients. However, legalising assisted dying is not the answer to this problem. Patients' fears of being kept alive by futile medicine will be replaced by the fear of being killed prematurely without their consent.[19] Rather what is needed is a relationship of trust, where the role of the doctor is to assist the patient in being in control of what happens. Patients want above all a doctor who will listen to them, take their concerns seriously, explain the options clearly and respect their wishes; a doctor who will strive to offer the best care available. This is what lies at the heart of the doctor-patient relationship. This is the way to calm patients' fears, and restore autonomy.
6. The 'right to die' will in reality be the right to be killed and will increase the power of the medical profession not the autonomy of the patient
In the Netherlands, some 30% of euthanasia requests are rejected by doctors on the basis that the patient's suffering is not sufficiently severe.[20] Conversely, approximately 1,000 deaths (0.8% of the total) are due to patients being killed against their wishes or without explicit consent.[21] The bill requires a doctor to make a judgement about the patient's request. Ultimately it is the doctor's assessment of diagnosis, treatment options, prognosis and the anticipated degree of future suffering that is the decisive factor, not the patient's autonomy.
Assisted dying legislation makes doctors less accountable and more powerful. Patients decide on the basis of information given to them by doctors. However it can be difficult to be certain in these areas; diagnoses may be mistaken,[22] prognoses misjudged, there may be new treatments of which the doctor is unaware, the doctor may not be up-to-date in symptom control. Furthermore, doctors are human and subject to temptation. Sometimes the decision-making of doctors may be affected, consciously or unconsciously, by other factors. These may include extrinsic pressures and influences, such as their own emotional state, previous personal experience, discussion with family members and the views of other health care professionals.
7. What about compassion?
If patient autonomy were the only yardstick by which decisions are measured, assisted dying would effectively be on demand. Furthermore we would agree that anyone who wanted to die, for whatever reason, has the right to do so. Clearly it is not just the desire to die but the suffering of the terminally ill that is driving this debate - the argument is that it is compassionate to end the patient's life if their suffering is severe. This is no longer an argument from autonomy but from compassion.
This argument accepts that killing can be compassionate and thus changes fundamentally the values of our society and the medical profession. In Scotland we have had up to now a different definition, based in the Judeo-Christian tradition, of what it means to be compassionate: 'to suffer with' (com-passion). Our nation has prided itself on developing ways to care for the terminally ill that have been envied the world over. Many initiatives in Scotland today offer support to developing palliative care world-wide, including Russia, Romania, India, Argentina, Kenya and China.
This bill would undermine the efforts of so many dedicated NHS and Hospice staff to continue to provide the personally costly service of caring for the dying.
Dr Derek Doyle, one of Scotland's pioneers in Palliative Care, who developed St Columba's Hospice in Edinburgh, said “to few of us is given the chance to care, but to all is given the challenge and the chance to relieve the suffering of our fellow men and women.”
Founder of the modern Hospice movement, Dame Cicely Saunders said “You matter because you are you and you matter until the last moment of your life. We will do all we can, not only to help you die peacefully, but to live until you die.”
Advances in palliative medicine mean that many of the unpleasant symptoms experienced during terminal illness can be relieved or substantially alleviated. While we acknowledge that some suffering cannot be alleviated, experience in the hospice movement has shown that restoration of dignity through creative care is possible for the vast majority. It is important that palliative care services and training are more widely available.
A study of over 1,000 doctors, nurses and social workers showed a negative correlation between willingness to endorse assisted suicide and knowledge of symptom management.[23] If assisted dying is legalised, the incentive for creative caring will decrease. Additionally, where doctors do not have good knowledge of symptom management, there will be an increased tendency to see death as the 'treatment' of choice.
The European Association for Palliative Care has re-affirmed its opposition to the legalisation of euthanasia.[24] If care is aimed at achieving 'the best possible quality of life for patients and their families' by focusing on a patient's physical, psychosocial, and spiritual suffering, requests for assisted dying are extremely uncommon. The answer is not to change the law, but rather to improve our standards of care.
Jack McConnell, First Minster said at the opening of the Scottish Parliament on 9th October 2004, “So, let us all be thinking persons. Let us all be open and adventurous. But most of all, let us be confident that we do live in a country of great talent and opportunity, of enterprise, and of compassion and tolerance too.”
We hope that by this response we can continue to keep the care of dying in Scotland thoughtful, of great talent, compassion and tolerance.
The above facts and arguments lead to the conclusion that:
Miss Jacky Engel BMedSci MPhil MA
CMF Research and Publications Assistant
Dr Peter Kiehlmann MBChB FRCGP DRCOG DCCH FPCert Dip CBT
GP, Aberdeen & Macmillan Lead Cancer GP NE Scotland Cancer Co-ordinating & Advisory Group, Clinical Senior Lecturer Dept General Practice & Primary Care, University of Aberdeen
Professor Alan Johnson MB MCHIR MA FRCS
Emeritus Professor of Surgery, University of Sheffield
Dr Mhoira EF Leng MBChB, FRCP (Glas & Edin), Consultant Palliative Medicine NHS Grampian, Honorary Senior Lecturer Aberdeen University
Professor Tim Maughan MB MRCP
Consultant Oncologist, Velindre Hospital
Honorary Professor of Cancer Studies, University of Wales College of Medicine
Dr Kathryn Myers BA MB MRCP
Consultant in Palliative Medicine, Hertfordshire
Dr Jim Paul MB MRCP
Consultant in Palliative Medicine, London
Dr Peter Saunders MB FRACS
CMF General Secretary
Dr Nigel Sykes BM MA FRCGP
Consultant in Palliative Medicine, St Christopher's Hospice, London
Steven Fouch (CMF Head of Communications) 020 7234 9668
Alistair Thompson on 07970 162 225
Christian Medical Fellowship (CMF) was founded in 1949 and is an interdenominational organisation with over 5,000 doctors, 900medical and nursing students and 300 nurses and midwives as members in all branches of medicine, nursing and midwifery. A registered charity, it is linked to over 100 similar bodies in other countries throughout the world.
CMF exists to unite Christian healthcare professionals to pursue the highest ethical standards in Christian and professional life and to increase faith in Christ and acceptance of his ethical teaching.
