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The XX Factor


Posted on 28 January 2010

gilderdale.jpgWere it not for the genuinely sad nature of the case, the last few hours of Lynn Gilderdale’s life could almost have about it the air of a grotesque Benny Hill sketch. In a surreal speeded up video, complete with that memorable theme tune, one might see Kay Gilderdale rushing around their home, searching out pills and potions, furious grinding in pestle and mortar, frantic googling, over-size syringes full of air…

…and all in very bad taste, Dr No fully agrees. But sometimes he wonders whether it isn’t necessary to look a little harder at the current wave of mother-love hysteria that has risen on the back of the Inglis and Gilderdale trials for murder and attempted murder of their respective children.

Frances Inglis may well have had ‘love in her heart’, but she also unilaterally decided to - and did - kill her son; Kay Gilderdale may well have been a devoted and loving mother, but she also undoubtedly tried to kill her daughter. She may even have killed her, but we shall never know, because the morphine that killed the daughter was administered by both, and it impossible to say which was the hand that killed.

Inglis’s jury returned a verdict of guilty (of murder), and got heckled in court and damned in the press for their pains; Gilderdale’s jury acquitted her (of attempted murder), and were hailed as heroes. And in each case, the underlying popular sentiment was an overwhelming swell of mother-love.

In the ensuing coverage, media mums competed to write ever more purple prose. No word of praise for the loving mums was too great. Inglis – in an echo to Mother Theresa – was promoted to Mother Courage by The Mirror. Not to be outdone, The Sun wheeled out Esther Rantzen to ‘salute the courage’ of suicide mum Gilderdale.

Dr No is nonplussed. It seems to him that the appeal to the virtue of mother-love – that somehow a mother killing her child is courageous when it is done with love in the heart – risks a triumph of a vulgarity over a broader sensibility. The dark and difficult moral question is smothered under a pillow of maternal hubris, and the moral tone descends to that of the soap opera. How long, he wonders, before Simon Cowell launches The XX Factor, in which ‘courageous mums’ with ‘love in their hearts’ compete to reveal ever-more ‘heroic’ acts of maternal love?

Vulgarity is one thing. The other, and more sinister, aspect of the mother-love love-in is that it is a cop-out. By focusing on the mothers, and their ‘gracious’ and ‘courageous’ acts, a diversion is created in which society can once again slip away into the shadows, and so avoid facing questions of immense and overwhelming difficulty. For the fact remains, these mothers killed, or attempted to kill, their children. No amount of purple prose praising their devotion and courage can alter that painful and awkward fact.

23 comments:

As you say Dr No, there are so many ethical questions here that need to be answered. First, I think discribing the mother as 'courageous' folllowing assisting her own child to die, is VERY wrong! So no praise for the media here!

And then you think, for a mother to watch a child in a vegetative state day in and day out for years and years is not an easy thing! Having to care for them as well! .. and watching them grow in looks but lifeless (you know what I mean) is hard! .. How hard? .. only god knows!

That said, does this complex amount of human emotions still give the right to any mother to take action in her own hands that also ends with the death of another human being; her own child?! Not in my book! .. Simply because you have to draw a distiction somewhere .. and generalise .. are people allowed to take such action in their own hands, for any situation, or not?!

Simplifying complex matters says No! ... But then I am not in this mother's position! Lucky me! ... then again, it's the use of the word 'Love' here that I find very troubling!

My first thought when cases like this come up is where's the support? Shouldn't there be some proper care in place to give her a quality of life? DLA at higher rate care and mobility. Direct Payments from Social Services to pay for care. Maybe a CPN if there's depression. A local befriending service. A decent day centre where you don't just vegetate but have meaningful social contact and activity or support to engage in activities in the community. Respite care at intervals as needed. Where is it all?

I'm sure that there are people out there that have virtually no quality of life, or none at all, but in this case, was it really impossible to give her a life worth living?

Euthanasia IS and always has been practiced;
http://www.guardian.co.uk/society/2006/jan/18/health.science

Unsurprisingly doctors seem to be some way ahead of Mums.

Once free of silly religious baggage one would have to be pretty heartless to sustain end of life degradation unnecessarily?

Interesting item here;
http://www.guardian.co.uk/society/2010/jan/16/charlotte-raven-should-i-t...

And here;
http://www.guardian.co.uk/lifeandstyle/video/2010/jan/07/tony-judt-motor...

Anonymous

From what I read, in the years leading up to her death, Lynn was unable to sit up without passing out. How would she have been able to leave her room to get to a day centre or access community activities? Also she was on a 24-hr morphine drip but was still in constant pain.

During her mother's trial, it was mentioned that Lynn had some very bad experiences at hospital. As a result, she became distrustful of the professional 'help' on offer.

.....

Surely the cop-out here and the questions that are being avoided are why it is that the NHS continues to claim that exercise and CBT are the only effective treatments for people as ill as Lynn?

Why isn't any proper biomedical research being funded to better understand Lynn's condition and how many more people will be left to suffer in such an appalling physical state like Lynn?

Focussing on the sensationalism of mothers and assisted suicide is all very well, but it avoids the real issue. Why are people like Lynn left to suffer for 17 years, to the point where death becomes preferable to life?

A&E Charge Nurse - I think in most cases doctors are more likely treating and relying on the doctrine of double effect and/or withdrawing futile and burdensome treatment at the end of an obviously terminal illness, rather than carrying out active euthanasia. No doubt some do 'euthanase' (horrible word...) their patients or assist in their suicide and get away with it - but I suspect it is rare (but we shall never know because they get away with it). I certainly don't think they are going round terminating the Lynn G's of this world on a regular basis.

Sam and Anon(s) - The question of Lynn G's diagnosis and prognosis is very central to all this - as is the question of where were her doctors? ME can be very debilitating, but it can be managed.

And as I said in my previous post, I too find the juxtaposition of love and killing unsettling...

"I certainly don't think they are going round terminating the Lynn G's of this world on a regular basis" - not yet, Dr No, but perhaps in time they will, albeit in strictly defined circumstances?

There have certainly been pleas from the Royal College of Obstetricians and Gynaecology to euthanise babies;
http://scotlandonsunday.scotsman.com/euthanasia/Plea-to-let-doctors-kill...

And there are well documented cases of doctors acting on their conscience to end suffering;
http://www.timesonline.co.uk/tol/life_and_style/health/article2051202.ece

http://www.independent.co.uk/news/uk/doctor-gave-fatal-injection-to-dyin...

If we listen to the likes of Charlotte Raven and Tony Judt the main issue for them seems to be about loss of control and the degrading effects of intractable symptoms, which, when combined, make going on simply too painful (psychically, more so than physiologically, although both are intertwined, of course).

I was particularly struck by Judt's metaphor about living in a cell that shrinks by 6 inches everyday because of MND - to me this seems absolutely terrifying.

Oops, dodgy link

Try this;
http://www.timesonline.co.uk/tol/life_and_style/health/article2051202.ece

Or, google, Dr Munro - Doctor gave babies fatal drug to ease distress of dying gasps (in the Times)

A&E Charge Nurse -

"Medics continue to wrestle with end of life decisions: "I certainly don't think they are going round terminating the Lynn G's of this world on a regular basis" - not yet, Dr No, but perhaps in time they will, albeit in strictly defined circumstances?"

This of course is what worries the like of Dr No and the Witch Doctor. Dr No certainly does not strive officiously to keep alive, but equally he has no intention of finding himself 'required' to terminate awkward/expensive/whatever patients, simply because that is what is expected of him by relatives/the hospital managers/the insurance company – or the State.

The RCOG proposal - so far as I know - never made in to practice. All the other cases you link to are so far as I know - correct me if I am wrong - end of life cases. Munro and the babies: both babies were all but dead when he administered a muscle relaxant to counter agonal breathing - so the doctrine of double effect could apply. Boyes was already dying when Cox administered the potassium chloride, so shortening her life by 15 minutes to one hour. But it was nonetheless attempted (attempted because the body was cremated, and if was not possible to prove it was the potassium chloride which killed her), and he was convicted but given a suspended sentence. It was clearly euthanasia (voluntary because Boyes asked Cox to end her life), but the case was some time ago (1991) - and there hasn't been a flood of similar cases since – that we know of.

Inglis and Gilderdale were different. Neither was already at the end of a terminal illness, and so already at death's door. In Inglis's case, the decision to kill was made was made without reference to Tom - which makes it involuntary euthanasia. In Gilderdale's case, she first attempted suicide, and then asked for assistance, which then progressed to attempted - attempted because the hand that killed was unknowable - euthanasia, this time voluntary.

Those who followed Dr No's posts and comments at the time we were considering Kerrie Wooltorton's case may recall that he accepts that a sane individual with a settled intent has the right to kill themselves. Respect for autonomy demands that be so. But in Wooltorton and in Gilderdale, the waters got muddied by their attendant conditions...and that is where it starts to get very very complicated, and the guard against creep becomes paramount.

Judt's description of MND could not be more chilling - and shows him to be a master wordsmith who's words will, to his great credit, live on long after he has gone. And Raven ends up rejecting suicide:

"The case for carrying on can't be argued. Suicide is rhetoric. Life is life."

If the law in England does not define euthanasia (it is murder, attempted murder, manslaughter or aiding and abetting suicide), then society has no legal reference for its definition of the word.

The Brunel University study on Euthanasia published in 2006 referred to above by A and E Charge Nurse) has been made an emotive issue by the Voluntary Euthanasia Society.

“This research proves that some doctors break the law and deliberately help patients die," said Deborah Annetts, chief executive of the Voluntary Euthanasia Society. "This is all done in secret and denied in public. Some of these doctors are acting compassionately on their patients' wishes, but some clearly act without consent. This cannot be safe."

The Brunel report in fact indicates that most “euthanasia” deaths are related to the doctrine of double effect practised by doctors for centuries and so perhaps arguably “good medical practice” rather than euthanasia.

Percentage of instances as proportion of total of 857 UK deaths in the Brunel University study.

(1) voluntary euthanasia = 0.16%

(2) physician assisted suicide = 0.00%

(3) ending of life without an explicit request from patient = 0.33%

(4) alleviation of symptoms with possibly life shortening effect = 32.8%

(5) 'non-treatment' decisions (eg: withholding or withdrawing treatment) = 30.3%

This study of only 857 deaths also extrapolates the figures from palliative medicine to indicate the number of all UK deaths that involve “euthanasia.” Extrapolating from this specialty is unlikely to be representative of all specialties.

Perhaps it is time to properly define the social meaning of euthanasia and separate it from and redefine the concept of “not striving officiously to keep alive.”

"The Brunel report in fact indicates that most “euthanasia” deaths are related to the doctrine of double effect practised by doctors for centuries and so perhaps arguably “good medical practice” rather than euthanasia".

Maybe, Witch Doctor, but the area remains murky, especially when we factor in cases were active treatment is withdrawn, in effect a means to hasten death just as effectively as one facilitated by increased measures of opiates, say.

While "Do Not Resuscitate" orders may also be problematic in some cases;
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC194097/

An interesting commentary concerning legal issues in the UK can be found here;
http://www.youtube.com/watch?v=3DHiSrRF0Ys&feature=related

It starts off with a claim by LSE Professor, Emily Jackson, that more than 100 Brits have headed off to Switzerland to end their lives - presumably those that can't afford a flight with Swissair, or fees (presumably) charged by Dignitas, then perhaps a certain pressure might be placed on the next of kin?

Witch Doctor - very much my reading of that study - normal practice whipped up by pro-euthanasia groups to show we are really all at it anyway...

Dr No still remembers the patient from whom he first learnt about double effect. He was a young bashful medical student sitting in a side room on the bed of a pretty young woman with terminal breast cancer. The senior registrar came in and said "If you carry on like that, you'll get struck off before you are even struck on!"

Dr No, like many others on the ward, was struggling with how could it be right that a bright intelligent young mother - she had children too - was soon to die. No one knew the answer. But the woman was in pain, and Dr No learnt that our duty as doctors was first and foremost to relieve suffering. That meant morphine. Even if it hastened death.

A&E Charge Nurse - the "Swiss problem" is about those of sound mind and settled intent who lack the funds and/or means. Withdrawing so-called life saving treatment from patients who are already dying is OK: it avoids futile and burdensome treatment - and can sit comfortably with a duty to save life - but not to stive officiously to keep alive.

It is interesting to note that policians are beginning to show concern regarding assisted suicide. Anne Widdecombe proposed an Early Day Motion -www.edms.org.uk/edms/2009-2010/302.htm - regarding the publication of an interim policy by the DPP on prosecuting assisted suicide. This policy has written instructions on how not be prosecuted.

I cannot imagine being in the position of Kay Gilderdale or Francis Inglis. I do not know whether I could/would assist a daughter to commit suicide or kill/cause the death of a son. Hopefully, I will never be put in that position.

I worry about the abuse of the ICP in that many good people have their life shortened - if only by a few weeks or months - as I believe the criteria or condition of a patient needed to initiate same can be variable from day to day.

There again, I hate the fact that I might have to attempt CPR on a frail ninety year old gentleman in end stage dementia as an Advance Directive is not in place. It is medically futile. I regard it as an assault on the dead. But I have to do it.

Barton is also about LCP(ICP) creep - only when she was doing it, it wasn't called the LCP. But the drugs and the idea were the same.

Euthanasia and mercy killing don't exist in English law, but they most certainly exist as social constructs (Dr No apologises for sounding like a sociologist). Of the two terms, the Anglo-Saxon get closer to the mark than the Graeco-Roman. It is killing to prevent further suffering. When it is done by way of a positive act - active euthanasia - it is clear cut. Inglis and Gilderdale were both about positive acts intended to kill (injecting morphine with intent not to relieve pain but to kill) and so are clear cut cases of active euthanasia (albeit qualified in Gilderdale's case by 'attempted' for the reasons given in the original post).

Where it gets blurred and confusing is at the boundary between passive euthanasia and not striving officiously to keep alive.

Not resuscitating Nikita's ninety year old chap with end stage dementia is withholding life saving treatment, and allowing him to die, but no one - unless they are bonkers - is going to say that is passive euthanasia. It is recognising the humanity of not striving officiously to keep alive.

Turning off a life support machine on a premature baby that is not going to survive is withdrawing life sustaining treatment - but should we say that turning off that machine is euthanasia, albeit passive, or a humane avoidance of futile and burdensome treatment, and so a recognition of the importance of not striving officiously to keep alive?

Dr No suspects the answer will turn out to be a medical rather than a moral one. It will depend on the underlying pathology and prognosis. Where there is significant underlying pathology that is itself likely to be lethal, then, he suggests, we are in the realm of not striving officiously to keep alive. Where no such pathology of lethal import exists, and we act to allow death, then we have moved into the realm of passive euthanasia.

In other words it depends on what actually kills the patient. If it is the underlying disease, then it is not passive euthanasia. If it is the absence of treatment (whether withheld or withdrawn) - as in withholding artificial feeding and hydration leading to death by starvation/dehydration, then that is passive euthanasia. It may also be not striving officiously to keep alive, but it has gone one step further and so has become passive euthanasia.

I am fiercely opposed to legalising euthanasia or assisted suicide, but I do think there were fundamental differences between these two cases. Kay Gilderdale had cared for her daughter more or less continually through her illness, and assisted her even though she did not want her daughter to die. Frances Inglis killed her son, going to considerable lengths to do so, simply because she couldn't accept that he was brain damaged, and after a very short period after his injury. This is why one was acquitted of attempted murder (even after admitting assisting a suicide) while the other was convicted of murder.

I wrote about the two cases here.

Matthew Smith - I agree the two cases have many differences, but the intention of this post was to remind us one of the similarities - that the red tops, by invoking the XX factor (courageous mums with love in their heart etc), were causing a moral distortion which drew our attention away from another similarity: regardless of how much love was floating around in the air, what these mothers were involved in was killing their children. No amount of saccharin spiel should cause us to forget that.

To understand why one jury convicted and the other acquitted, I think we need look no further that the legal process. Inglis was charged with murder, and had undoubtedly murdered. It was also evident that she had unilaterally decided that Tom should die. One could even say that, despite all that love floating around, it had an almost cold-blooded air about it. But the facts of the case were so overwhelming - that it was premeditated murder, that only the most perverse of jury could have even contemplated acquittal. In real life, a guilty verdict was inevitable.

Gilderdale, on the other hand, admitted a charge of assisting a suicide, and was additionally tried for attempted murder (murder being unprovable - reasons given earlier). The facts of the case add up to a conclusion that she did attempt murder, but the jury, which may be instructed by the judge to weight the facts, and the facts alone, of the case, nonetheless exercised its ancient right to consider the wider aspects of the case - in effect try the trial - and they chose to throw it out, regardless of the facts. The were saying, in effect, she may or may not be guilty on the facts, but we don't think the girl done wrong - and so they acquitted.

This process - the jury choosing to reject the charge - is known by the somewhat opaque term jury nullification. Ponting is a recent relatively well known example.

I agree in part that the "XX factor" and "mother love" are overplayed; mothers can be incredibly selfish people. On the other hand, controversies involving euthanasia and assisted suicide often involve male carers such as the partner of Debbie Purdy. Male carers have also received leniency from the courts and prosecution service over such killings (I recall a gay man interviewed on Radio 4 who had smothered his partner who was in the late stages of skin cancer, and who wasn't prosecuted).

However, the mitigating factors were very much stronger with Kay Gilderdale, due to her long history of care and the clearly expressed wish of her daughter to die. Something Anne Atkins said in the Daily Mail rings true here (much as the rest of her article doesn't, especially the "I know the curse of ME, so I know etc" tone), which is that caring for someone for that period of time can impair judgement. However, I think the love in question here was very genuine (it need not have been mother love) even if the actions were misguided and wrong.

I also think the Daily Mail have jumped on this as an ideal provincial human interest story; the Gilderdales were a model of respectability, the mother had given up her career to care for Lynn, Lynn was pretty and white and lived in a Sussex village, and so on. They were the Mail's "kind of people" (they wouldn't have reported on a similarly afflicted black woman in inner-city London, except to demonise her and her mother) and less than a fortnight before their outpouring of sympathy, they ran a reader poll saying "is ME real?" (when reporting her death, their headline ran "Devoted mother arrested over 'mercy killing of yuppie flu daughter who died of massive morphine overdose'").

Jury nullification is a very important right; potentially, it allows juries not to submit defendants to over-harsh, politically-motivated penalties such as life without parole for a juvenile who acted as a lookout in a robbery in which someone got killed (this is the case in many US states). As for Ponting, he invoked a "public interest" defence which was in the Official Secrets Act of the time, so his acquittal was entirely legitimate even though the judge directed a guilty verdict. The clause was removed from a revised act.

What was the judgement in the Inglis case, trying to achieve?

Is it really so that it is alright to kill your child because you love it, and that love is taken as a "given". What an extraordinary assumption. How is any court of law able to define love?

Assisted suicide is against the law - now we have legal and dangerous precedents to say it's OK if one loves the person one assists and providing one can prove love anyone can use this as a reason. Why would a loving child expect the mother to assist her, putting her at risk of prosecution, and why would a so-called loving mother comply?

Similarly why would a doctor obey any AD desiring "euthanasia" when actually a patient cannot demand treatment, bearing in mind that according to the GMC "no treatment" is still "treatment".

If a patient has a "poor prognosis" and is in the "terminal stages of dementia", so that medication and even fluid and food are withdrawn, does that not make the "poor prognosis" a self fulfilling prophecy? Patients with dementia rarely die of dementia per se - they die of lack of care. 40% die of "chest infections", others of concomitant conditions for which life sustaining medication, because of the "poor prognosis" and the supremacy of the dementia is withdrawn. Dementia seems to frighten doctors, mainly because they cannot cure it.

Doctors are literally able, at the stroke of a pen on the drug chart, to control life and death. Sometimes with the agreement of relatives, and sad to say, sometimes not, even when
patients are not actually dying.

I get extremely exasperated at this obsession with dying and when.

Making a dying patient as comfortable as possible if they are indeed dying is the role of the doctor.

It's another thing however to accelerate death because the person is old and going to die anyway. This is discrimination. Their life is theirs whether it be for a day a month or a hear. I believe as a philosopher that the life is the property of the person in the sense of ownership and in the sense of attributes. This allows suicide, i.e. death by their own hand. It also allows life.

It does not mean that people should have the right to demand that a doctor or a loving relative should kill them. or that the law should force particularly doctors to kill on demand. Nor in some cases should doctors "euthanase" a patient because of a "poor prognosis".

Nor should laws be written to allow assisted suicide just because people do it and some want it.

If we are not careful this constant drip drip of ethical claptrap and consequent badly written laws is going to make doctors (already accountants) into executioners, and the trust of patients they have had in the past and so deservedly earned, will dissipate.

Intertwingler - 'and the trust of patients they have had in the past and so deservedly earned, will dissipate' - a key point and one we should not overlook.

When we are old and frail, and yet do not want to die, how will we feel should the day come when our attending doctor has the legal authority to kill on demand? A doctor whose last or next patient may die at his hands? Will we not wonder when it will be our turn?

"If we are not careful this constant drip drip of ethical claptrap and consequent badly written laws is going to make doctors (already accountants) into executioners, and the trust of patients they have had in the past and so deservedly earned, will dissipate".

Interwingler - many nursing, and certainly most medical students will have played the 'who gets the liver' game.

It goes like this - x5 sick patients (all needing a new liver) but only x1 organ available - how do health professionals decide who gets it.
The first and most important rule is that not EVERYBODY can be saved due to supply and demand (a reality born out in the real world, incidentally).

A % of patients who died today will not have received adequate palliative care, while others will have suffered a significant deterioration in their condition (and may even have died) simply because the NHS is trying to be all things to all people.

If doctors treat oldies more aggressively and each patient has a further 6, or even 3 months of life (including the cost of expensive residential care, etc) who is to be deprived of medical attention because, as the students learn in the frustrating 'liver game', not everybody can be saved, no matter how good your intentions are.

A & E Charge Nurse

This is a really bad analogy especially considering the process by which a liver is deemed suitable or not by transplant teams.

What you are saying is that "oldies" as you put it (despite the age discrimination act or the disability act) needing relatively simple treatment & care are ignored because they "probably don't have long to live", and therefore are deprived of all sustenance and medication so that they die.

Furtheremore you opine, this is expected as "collateral damage". WHY not you quickly get hem to sign an AD (computerised spit-out)just to make it safer for your staff?.

Don't worry about Livers when there's an elephant in the room.

Yes, 'oldie' is an irreverent term but one I'm rather fond of, perhaps because Richard Ingrams still makes me chuckle;
http://www.theoldie.co.uk/

Anyway I seem to recall the word 'girlie' cropped in the context of the Kerrie Wooltorton case and one or two commentators were taken to task about its appropriateness - I guess we all have to be very careful about the words we use nowadays for fear of offending somebody or other?

As to the substantive criticism of the 'liver' metaphor I would beg to differ about its relevance.
In my mind there will always be a DIRECT CONSEQUENCE (for different patient groups) following decisions about the availability and allocation of health resources?
The whole point of the 'liver exercise' is to illustrate the kind of machinations that the likes of NICE must wrestle with before deciding how best to spend our money (because somebody has to, irrespective of whether or not bodies like NICE are considered the best way to tackle such problems).

It is all too easy, although somewhat pointless, to suggest that everybody can have everything in all cases?
Surely the history of chronic underfunding and poor service (in the main) tell us that as a society we simply do not place much of a value on our elderly - and we cannot blame the poor old NHS for that?

If it is decided that the elderly are to receive a standard of care that a variety of pressure groups have always clamored for, then the first thing we have to agree on is which other services are to be cut, since such work is both labour intensive and very expensive.
Maybe such changes can be achieved - I'm not such a pessimist as to believe that it can't, but I tell you now, the worried well are not going to like it, they are not going to like it one bit, especially given the convenience they crave will have to be sacrificed on the alter of a patient group whose needs grow exponentially with every new drug, and every technical innovation?

Perhaps we can at least start with this unpalatable truth before deciding how much we should or shouldn't be doing for those oldies who are very frail or demented?
I still maintain (from both personal and clinical experience) that death is not the worse thing that can happen after an oldie reaches a certain point.

I've been thinking it over and over again, and... you can call the a pitiless bastards\, but I wouldn't call the act courageous, even with all the motherly (or fatherly) love. Vegetable state does't mean that there is no one there inside - life, thoughts and feelings, even when there are not signs. Fight until the end is what makes sense, working hard to use the best medical advancements, etc. Because there won't be another chance. In addition, legalized assisted suicide will add another problems - too many "assisted" deaths won't actually be suicides at all. It will turn into a legalized murder.


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