The assisted suicide/ euthanasia debate

Dr C Bates

UK current situation

• Suicide act (1961)

• Murder act (1965)

• 1994 – House of Lords review committee oppose change in law

• Lord Joffe Assisted Suicide Bill– Select committee report produced– Defeated in house of Lords May 2006– 148 votes to 100

Euthanasia ‘Opposers’

• Arguments against change in the law are not based on a religious/ pro life message

• Public safety

• Protection of the vulnerable

• Legal issues around certainty and safeguards

“All cats have tails” fallacy

Arguments for…

• We want it – the autonomy argument

• We need it – the compassion argument

• We can control it – the public policy argument

Time for a change?• “82% of the public support patient choice, they realise

that dignity is a personal matter” ?– (Chief exec of VES/ DiD)

• No: Be aware of where public opinion statistics have come from– The group sampled– The question asked– The hidden agenda/ driving force

House of Lords select committee in 2005 concluded that current research into public and health sector attitudes can not be accepted as representative of authentic opinion within the UK.

Requests for assisted suicide

• Rare

• 100 British people have used ‘Dignitas’ in the last 5 years

• 3 000 000 deaths from all causes over last 5 years in UK

Practical problems/ death with dignity?

• 15% of Dutch and Oregon cases are problematic

• Vomiting, muscle spasms, extreme gasping, distress

• Re-awakening of the patient

• Dr then needs to step in to complete the process

Arguments against..

• Autonomy is not absolute

• Pressure on the weak and vulnerable

• Slippery slope

• Inadequate safeguards

• Damage to the Dr-patient relationship

• Access to Palliative Care needs improving

Autonomy arguments

• My autonomy is not absolute

• I am part of a wider society

• Exerting my autonomy may compromise someone else’s

Autonomy and law

• European Convention on Human Rights –

• A terminally ill or dying person’s wish to die cannot constitute a legal justification to carry out actions intended to bring about death (1999, article 2)

Protecting the weak and vulnerable

• Life has intrinsic not extrinsic value

• The sick, dying and disabled are vulnerable and need protection from the law

• PAS as a treatment option may turn the ‘right to die’ into a ‘duty to die’

• Oregon evidence

Slippery Slope

• Elastic interpretation

• Hidden pressure

• Abuse of the law

• Paradigm shift

Safeguards are Inadequate

• Dutch safeguards have not stopped the slippery slope

• 1995, 31% of dutch drs didn’t report because they knowingly breached the guidelines

• Oregon is not a success story either– Self reporting by PAS drs– Only 5% have psychiatric evaluations– 1 in 6 people using PAS had treatable depression

(BMJ Oct 08)– No way of tracking prescriptions

We need it: Compassion

• Society’s duty to alleviate unbearable suffering

• Even if this means helping patients kill themselves

• Palliative Care failure

Palliative Care issues

• Good quality palliative care is not universal in UK

• Examples of poor care are common

• Fear around death/ mode of dying huge

• Evidence from abroad is worrying

• Investment in end of life care is the answer

Means and Ends

• Refusing/ discontinuing life sustaining treatment is legal

• Treatments may not be considered worthwhile and stopped

• Intention and causation is key

• Jumping, slipping or being pushed off a cliff are different though end is the same

Is there any common ground?

• Focus on importance of reducing human suffering

• Aversion for over-technical hospital death

• Importance of control for the patient

• Death is not the ‘worst thing that can happen’

• Search for a ‘good death’

Hurst & Mauron Pall Medicine 2006

Is doctor support for euthanasia really growing?

• Change in the law opposed by:– World Medical Association– BMA – very strong position statement– RCGP– RC Psych– Association of Palliative Medicine– Royal College Physicians

• 73% members oppose change in law

What should we do now?

- Understand autonomy- Demonstrate unambiguously to

people with terminal illness that they are not a burden to others

- Improve pain and symptom management/ palliative care