Behind The Medical Headlines

Euthanasia today (update)

• Rev K Boyd, Professor of Medical Ethics, University of Edinburgh, Scotland
• Dr L Campbell, formerly University of Edinburgh, Scotland

Summary

Euthanasia and physician-assisted death present a major ethical and legal challenge. Should a doctor seek to prolong life at all costs or should a doctor assist to end suffering if requested by a patient? Would a system of doctor-assisted death put unacceptable pressure on doctors or make patients feel pressured into ending their lives prematurely? Dr Lorna Campbell and Professor Kenneth Boyd provide an overview of this emotive ethical area.

Declaration of interests: No conflict of interests declared.

Introduction: historical perspectives

‘To please no one will I prescribe a deadly drug, nor give advice which may cause his death.’ These words from the Hippocratic Oath (3rd to 6th centuries BC) date from a time when medical practice was not regulated and suicide might be approved if it was committed for ‘noble’ reasons. The physicians who originally took the Oath are now thought to have been a reforming minority, influenced by religious respect for life but also anxious to dissociate themselves from those who misused pharmacological knowledge for nefarious purposes. Later, the Oath was adopted by physicians in the Jewish, Christian and Islamic traditions, all of which prohibited suicide because the time of death was for God alone to decide, and because suffering might be an opportunity for spiritual growth. But compassionate relief of suffering, by medical means where available, was also central to these traditions. In Judaism and Christianity today, drugs may be used to relieve terminal suffering, even if they incidentally hasten death, provided that the intention is to relieve and not to kill.

Against this, a more secular view of life and death argues that since modern medical means of prolonging life may also prolong dying, medical means of assisting death should not be denied to a competent terminally ill patient who sincerely wishes this. Many religious authorities agree that there is no duty to prolong life at all costs, and that when the burdens of treatment outweigh its benefits such treatment may be withdrawn. But they remain opposed to active and intentional killing.

The word ‘euthanasia’, hitherto meaning a calm and peaceful death, was first used to advocate physician-assisted suicide in the late 19th century, when developments in pain relief meant not only that suffering could be managed much more effectively, but also that death could be accelerated by administering sufficiently large doses of chloroform. In Britain a voluntary euthanasia movement, around one quarter of whose original members were doctors, was founded in 1935. Both before and after World War II a number of attempts were made to legalise voluntary euthanasia for adult patients suffering from fatal, incurable illness characterised by severe pain. None of these were successful. The Nazi atrocities clearly had an impact on post-war debates on the subject, with concerns being expressed about the possibility of ending vulnerable patients’ lives without their express consent.

Developments since 1960

During the 1960s, the emergence of the hospice movement provided greatly improved pain relief and care for terminally ill patients, and this, it was argued by many doctors, rendered calls for legalised euthanasia redundant. The imperative was not to legalise euthanasia, but to make more widely available in hospital wards and patients’ homes the standards of palliative care pioneered in hospices. In this context, two distinctions, between killing and allowing to die and between foreseeing and intending that measures to relieve pain and suffering may lead to death sooner rather than later, are important moral considerations for many doctors opposed to the legalisation of euthanasia or physician assisted dying. By contrast, other doctors and health care professionals, and also a number of philosophers, argue that these distinctions obscure the real issues and are at worst hypocritical.

Since the 1960s, some countries have legalised euthanasia or physician-assisted suicide. Both the Netherlands and Belgium have passed laws permitting doctors to help terminally ill patients to end their lives; and in Switzerland assisted suicide has been legal since 1942, provided that those helping dying patients can show that they are acting from altruistic motives. In the US, only Oregon has legalised euthanasia, and in Australia the federal government reversed a law permitting assisted suicide in the Northern Territories.

The legal situation in the UK

Euthanasia and physician assisted suicide remain illegal in the UK, but between 2003 and 2006 some parliamentary attempts were made to legalise ‘assisted dying’. An ‘Assisted Dying for the Terminally Ill’ Bill, designed initially to allow voluntary euthanasia but later limited to allowing a physician to prescribe medication which a patient could take to end their own life, was introduced into the House of Lords, where it was the subject of an exhaustive report by a Select Committee. Opinion in the Committee was divided and it made no recommendation on legislation, but in May 2006 the House of Lords decided against taking the Bill further.

A similar proposal in the Scottish Parliament in 2005 also received insufficient support to proceed. Medical organisations, including the Royal Colleges and the British Medical Association, were initially inclined to take a neutral stance, believing that the matter was one for society as a whole to decide. They had serious reservations, however, about the moral and practical implications of interpreting and implementing the proposed legislation, and after discussion and consultation with their membership, most UK medical organisations, but not all doctors, expressed their opposition to legal change on assisted dying.

British public opinion

Public opinion in Britain appears to be swayed, sometimes in favour and sometimes against legalising euthanasia, by current high-profile cases. In 2002, the European Court of Human Rights rejected the request of Mrs Diane Pretty, a patient in the terminal stages of motor neurone disease, to grant her husband legal immunity if he were to help her to die. The Court ruled that the European Convention on Human Rights did not confer a right to die, and that English law against assisting suicide should be upheld. But in another case occurring at the same time, the English High Court ruled that Ms B, a patient like Mrs Pretty in her forties and paralysed but unlike Mrs Pretty not terminally ill, should be granted her competent request to have artificial ventilation withdrawn, even though this meant that she would die. These legal rulings were criticised both by advocates and opponents of euthanasia. The advocates argued that the inconsistent outcomes depended on an indefensible distinction between acts and omissions, while the opponents argued that since Ms B’s clear intention was to die, the judgement in her case undermined the law’s prohibition of suicide. Mrs Pretty’s case attracted much public sympathy, but this sympathy in turn was tempered by fears about vulnerable patients being killed without their consent. At the time, Harold Shipman, an English general practitioner, had recently taken the law into his own hands and murdered a large number of his elderly patients.

British public opinion was again swayed in both directions by two further cases. Sympathy was expressed for Mr Reginald Crew, another patient with motor neurone disease, who in 2003 travelled to Switzerland for assisted suicide. His wife, who accompanied him, was not subsequently prosecuted because the authorities saw ‘no public interest’ in doing so. But concerns were subsequently expressed when Mr and Mrs Stokes, a couple in their fifties and neither terminally ill, were both assisted to die by the same Swiss organisation. Following Mr Crew’s case, but before that of the Stokes, a survey of 1,000 British doctors found that over half agreed that terminally ill patients should be allowed to seek physician-assisted death, but only one third agreed that the law should be changed to facilitate this. These views may seem inconsistent. But that may be because while these doctors feared that current arrangements fail patients like Mrs Pretty and Mr Crew, they also feared the alternative – as one doctor told the British Medical Association, ‘We shall start by putting patients away because they are in intolerable pain and have not long to live anyway, and we shall end up by putting them away because it’s Friday night and we want to get away for the weekend.’ Euthanasia, in other words, may be a moral question for which no legislative answer, either way, will ever be ethically satisfactory.

Debate in the UK about these issues was revived in 2008 by two further cases. Ms Debbie Purdy, who has multiple sclerosis like Mrs Pretty, has asked the High Court to clarify the law by stating whether her husband would be prosecuted if he assists her to die – in this case by helping her to travel to a Swiss clinic. Daniel James, a 23-year-old who was paralysed by a rugby accident but was not terminally ill, did travel to a Swiss clinic, where he was taken at his own wish by his parents, whose action is now being investigated by the police. At the time of writing, the legal authorities have yet to respond in both of these cases, and their influence on public opinion remains uncertain.

Further reading

Boyd KM. Mrs Pretty and Ms B. Journal of Medical Ethics 2002; 28:211–2.

Kemp NDA. ‘Merciful release’. The history of the British euthanasia movement. Manchester: Manchester University Press; 2002.

Keown J. Euthanasia examined. Ethical, clinical and legal perspectives. Cambridge: Cambridge University Press; 1995.