06 Jul

Assisted Dying

Posted By Politybooks

Mark-C-300x200This post deals with the issue of euthanasia/assisted dying (as discussed in Chapter 7 of Ethics for OCR Religious Studies) and Lord Falconer’s Assisted Dying Bill, currently before Parliament. It sets out some background together with arguments in favour of assisted dying. A later post will set out arguments against.

Background: Lord Falconer’s private members’ bill on assisted dying is currently before parliament. Whilst 70% of the public support the legalisation of physician-assisted suicide for the terminally ill, parliamentarians are generally more cautious, aware of the complexities of applying law and regulating cases of abuse, so this bill is unlikely to make it into law. When Jack Kevorkian (the American doctor imprisoned for assisting in the suicides of 130 ‘patients’) started out, it was a crime in every country but Switzerland. Today, the Netherlands, Belgium, and Luxembourg allow physician-assisted suicide, but the annual total of assisted deaths in these countries ranges from 0.5%-3%. Parliaments in New Zealand, Quebec, New South Wales in Australia and in the UK are debating the issue. Here in the UK, prominent cases have raised the issue of a need for a change in the law. For example…

Jeffrey Spector (2015)

Terry Pratchett (2015)
See his film: http://www.dailymotion.com/video/xnu340_terry-pratchett-choosing-to-die_shortfilms

Deborah Purdy (2014)

Daniel James (2008)

Diane Pretty (2002)

Since 1993, passive euthanasia has not fallen within the definition of assisted suicide. This involves the removal of life support, or withdrawal of treatment deemed futile, for example, in cases where nothing further can be done to improve the condition of a patient. In such cases their dying, not living, is being extended.

In 2010, the Director of Public Prosecutions added guidelines to clarify the 1961 Suicide Act. He stated that prosecutions for assisting in another’s suicide would be less likely to be pursued if it was deemed not to be in the public interest (i.e. where a jury would be unlikely to convict a friend or relative acting on compassionate grounds, and pursuing such cases would be a waste of time and money as well as being unnecessarily distressing for relatives of the deceased). The guidelines can be viewed here.

In 2013, the government announced that it was phasing out the ‘Liverpool Care Pathway’ which aimed to ensure that patients who were in their last days and hours died comfortably and peacefully along the lines. It had been criticised by many who testified that their elderly relatives had been put on this pathway without their consent. Some relatives saw the deaths of their relatives as being hastened by the over-prescription of drugs which diminished the desire or ability to accept food or drink, and through the withholding or prohibition of hydration (see More Care Less Pathway).

Furthermore, a Freedom of Information Act request in 2012 established that 2/3 of NHS Trusts had received incentive payments for meeting ‘targets’ for using the Liverpool Care Pathway, totalling £12million. An individual care plan approach has now replaced the LCP.

A great place to begin thinking about the issues involved is The Westminster Faith Debate on ‘Should we legislate to permit assisted dying?’ Members of parliament debate the legal and ethical implications of a euthanasia bill here.

How ‘dwindling’ has put assisted dying on the agenda

In 1945, male life expectancy was around sixty-five. Death typically came with vital organ failure or cancer, and little could be done for patients. Today, ‘dying’ has turned into ‘dwindling’ and there is an arsenal of pharmaceutical and surgical weapons to stave off death. Conditions like Alzheimer’s and Parkinson’s disease, and the prospect of decades of dependency and expense lead many to want the option of physician-assisted dying, or living wills/advance directives (e.g. to specify a wish not to be resuscitated in the event of having Alzheimer’s disease and having a heart attack in a hospital ward). One US study (McLean, 2007) estimated that 40% of us will experience prolonged dying and 15-20% some form of dementia.

Below, we’ve presented some of the points in the case for euthanasia as acronymns, which can help with your retention and recall in an exam.

Reasons given in favour of physician-assisted dying

Biographical vs Biological: Philosopher James Rachels argues that quality of life matters and distinguishes biographical life (with self-awareness, a sense of oneself and of having a past and a future, desires and interests, and relationships with others) from mere biological life. In the UK, there are around 1500 patients who have been in a Persistent Vegetative State (PVS) for more than three months, after which their chances of recovering self-awareness are very low (though the condition can be misdiagnosed). Sanctity of life absolutism can obscure the fact of a quality of life that is so low as to be (in the subjective judgment of its bearers) not worth living.

Maleficence: The technology available to doctors (to take over lung function, maintain blood pressure and do dialysis of livers or substitute for failed kidneys), raises the question of whether such extraordinary means of keeping PVS patients alive can be regarded as harmful when they go against the interests that a patient has expressed in a living will, or those of their next of kin. So beneficence (the duty to act for the benefit of others) can be in tension with non-maleficence (the duty to do no harm). Care can deliver a quality of life deemed to be a ‘fate worse than death’, namely maintaining a patient with no prospect of recovering their cognitive functions, yet maintained indefinitely in a manner which distresses their next of kin who are forced into a mourning period with no end in sight. When so many patients of sound mind and body can specify the terms under which they would wish not to be resuscitated are denied their wishes, this condemns them to lengthy lives. In Peter Singer’s view, this does ‘harm to those whose misery is needlessly prolonged.’ ‘CPCR’ (cardiopulmonary-cerebral resuscitation) is perhaps a more helpful term than CPR as it is the brain (more specifically, the cerebral cortex where cognitive functions operate, as opposed to the part which maintains normal breathing, heartbeat, and unconscious functions), not the heart that is key to personhood and resuscitation.

Autonomy and Patient Choice: US pro-euthanasia activist and physician-assisted suicide practitioner Jack Kevorkian once said, ‘In my view the highest principle in medical ethics…is personal autonomy, self-determination. What counts is what the patient wants and judges to be of benefit or value in his or her own life.’ Generally autonomy is taken to require consent along with competency, a lack of pressure, and a sustained and properly informed decision. Kant’s understanding of autonomy is not simply, ‘what I want’. There are limits to autonomy – reason links this into the universal moral law and takes no account of hypothetical imperatives like, ‘If I am in unbearable pain, I can ask a physician to assist in my death,’ because they cannot be universalised. Utilitarians argue that our Judeo-Christian ethic is outdated. Peter Singer produces five new commandments in his book Rethinking Life and Death, the first three of which are: 1) Recognise that the worth of human life varies; 2) Take responsibility for the consequences of our decisions (in end-of-life care); 3) Respect a person’s desire to live or die. Such preference utilitarianism is about choice. Dying threatens uncontrollable pain and distress, and even if patients do not take up the choice of assisted dying, having the option brings these factors under a degree of control.

Dignity: The loss of bodily and mental functions and the feeling of dependency and being a burden on others causes many like those in the cases listed above to want to end their lives before their human dignity goes. Deliberately ending life at a time and condition of one’s choosing is an attempt to take control of the suffering and pain, foreshortening the extended dying process.

Economics: A defence against the charge that assisted suicide is about saving money. In the Netherlands, where Assisted Dying accounts for 2.7-3% of all deaths, this might lead to patients forgoing an average of four weeks of life and save about 0.07% on healthcare costs. So proponents of euthanasia say it’s about patient choice, not saving money (though if these figures were the same in the US, it would make an annual saving of $627m, far less than 1% of total healthcare costs). In response to the argument, the Netherlands and Belgium, which have assisted suicide, also have better palliative care than their European neighbours that prohibit it. Unscrupulous relatives and doctors can be regulated by legal and procedural safeguards implemented in the care of the elderly and dying.

How would opponents of assisted dying counter the above arguments?

If you were to rank these reasons in order of importance, which three would come first?


Mark Coffey is a teacher of Religion and Philosophy at The Manchester Grammar School and an associate lecturer in ethics at The Nazarene Theological College in Didsbury. An Oxford theology graduate, he did a Master’s degree by research on Hauerwas at Leeds University under Nigel Biggar. He is a regular broadcaster on BBC Radio 4 and has written an introduction to the theological ethics of Stanley Hauerwas.