You are hereBlogs / dr-no's blog / MSPs Euthanase Assisted Dying

MSPs Euthanase Assisted Dying


Posted by Dr No on 04 December 2010

airplane_3.jpgIt has been a bad week for legal homicide. McMargo, Scottish champion of assisted dying, saw her End of Life Assistance Bill expire as eighty-five to sixteen Holyrood MSPs voted on Wednesday to give the proposals a fatal injection. The day before saw the launch of the own-goal Commission on Assisted Dying – an ‘independent commission’ bankrolled by the well known pro-death hat-stand Gaga Pratchett, set up by Dignity in Dying, and headed up as it is by the well known ‘make it Zurich for me’ proponent, Lord Falconer, whose selection of ‘independent commissioners’ is notably slewed towards fellow flight attendants, plug pullers and pillow snuffers. If this panel achieves true independence, so too will the Vatican’s Commission on God: Does He Really Exist?...

What McMargo and The Lord Flight Attendant are about, although they don’t put it in such terms, is liberalising the law on homicide. Suicide is properly no longer a criminal offence – there was nothing to be gained and much harm to be done by criminalising the act – but both homicide (the killing of one human being by another) and assisting suicide (in effect a form of partial homicide) remain, apart from the obvious clear exceptions in the case of homicide, criminal acts. What McMargo and The LFA intend is to relax that law: that is, to extend the bounds of legal homicide.

The Mob, just as it does for capital punishment, tends to favour death. A poll relied upon by McMargo reported almost four out of five respondents backed the proposed relaxation in the law to allow assisted suicide. Similarly, as an example, the majority Daily Mail ‘vox pop’ response to both the trial and appeal of filicidal Frances Inglis praised her courage in carrying out what others have called the ‘ultimate act of love’. And yet legislators and the judiciary remain to immune to the bawl of the Mob. Time and again our legislators reject change to the law; just as for Inglis, our judges rejected her appeal against conviction – she remains a murderess, even if her sentence was reduced.

Are our legislators and judges right to reject the will of the Mob? Dr No thinks they are. Put bluntly, the Mob is louder than it is intelligent or for that matter informed – a wider reading of the Inglis case suggests that Inglis was not so much killing ‘with love in her heart’, as extirpating her own understandable but insufficient to justify murder agony at the plight of her son. And yet, we are considering, quite literally, matters of life and death. We should be guided more by careful thought, than by the spontaneous but all too often thoughtless outpourings of the Mob – or the ill-thought out arguments of the more organised members of the pro-death lobby.

Much of the rhetoric of the pro-liberalisation lobby relies on the right to self-determination – the right of an individual of sound and settled mind to determine, without interference from the state, the time and manner of their own death. This is somewhat disingenuous, given that such self-determination, being suicide, is not illegal; and yet there is a proximal bleed of the liberal intent into related, currently criminal acts; a broadening and blurring, predicated on a notion that if suicide is not illegal, then surely a well intentioned compassionate assistant should not either considered a criminal?

In a pure, untainted world, such might even be the case. What McMargo, The LFA and all their pals – including the loud and vocal ‘how dare parliament tell me when I can die’ brigade – forget is that, even in a free society, there are some freedoms that must be curtailed, not with any intent to curb determined self-determination, but to protect those at the opposite end of the spectrum. The articulate will express their will, and for those in whom the will is strong enough, there will always be ways and means. Their fate need not concern us. What should concern us – in a civilised society – is the scope, in a loosened liberalised and perhaps unavoidably blurred reframing of the law on homicide, to allow, even foster, the emergence of sometimes overt, more often subtle and covert, pressures on the frail, weak and feeble to take the Warnock ticket, and end their days early, on a matter of social conscience and sensible convenience.

Let us be in no doubt. Those of sound and settled mind who wish to kill themselves are already free – whether we regret it or not - to do so under our moral and legal codes. What concerns us here is a liberalisation of the law of homicide, a blurring of boundaries, an accession of shades of grey. But, as in life and death itself, this is a matter that brooks no shades of grey. The moment we allow ourselves even the option of the assessment of lebensunwürdigen lebens, of ‘life unworthy of life’ in others, then we have cracked open a door to a sliding scale of harsh judgements, set on a skidpan of moral ice that, as night follows day, can only end here.

Or – to put it more formally: this, of course, is our old friend the deontological (do what is right and damn the consequences) opposed to the consequential (consequence rules) argument. It may well be deontologically proper to allow assisted suicide – but the real world consequences are just too awful.

15 comments:

We really do.

We just love the clean, fresh, minimalistic appearance of the "Commission on Assisted Dying" website.

Its pristine appearance seems to engulf the brain with a purity so pure and a whiteness so white that it makes you want to die purely and cleanly and impeccably with minimal fuss.

Not only a "good" but a "pristine" death is surely on offer?

My Black Cat is particularly taken with the "Eye of Demos logo" on the bottom left hand corner of this flawless, virgin website.

She hopes that, now that she has pointed it out this Demos logo, it doesn't do a disappearing act.

These things happen, you know.

"Let us be in no doubt. Those of sound and settled mind who wish to kill themselves are already free – whether we regret it or not - to do so under our moral and legal codes" - yes, that is true, but what is rather less free is the means to end one's own suffering due to lack of access to the sort of technology that would make the final act itself less hit & miss, or frightening.

Perhaps the time has come to make paralysing agents, potassium, barbituates and the rest of the paraphernalia available to those who satisfy certain criteria?
Admittedly the cannula issue remains problematic but if this could be overcome then doctors would be free from the burden of being implicated in certain forms of suffering which at the moment remain subject to a medical framework (including the medical mindset that goes with it) - irrespective of the dying wishes of the individual.

Personally I do not think the argument that a dying person must suffer the degradations of the final stages of a terrible illness in order to protect others as terribly convincing.
I also think you undermine a very interesting piece by characterising those who do not share your point of view as "the mob" - I find it impossible to believe that somebody as erudite as your good yourself remains oblivious to the academics, and indeed medics who are arguing for more humane treatment at the end of life?
http://www.guardian.co.uk/society/2010/feb/25/assisted-suicide-doctor-an...
http://www.guardian.co.uk/commentisfree/2008/oct/19/euthanasia-daniel-ja...

The semantics of what label is given to these deeds is largely irrelevant - what matters is the relief of suffering and the ability to recognise that the end of life is not necessarily just a medical matter?

a&e charge nurse - The mob was shorthand (and not very good shorthand – so fair comment - I meant to find a better word but didn't get round to it) for unthinking knee-jerk responses of the type to be found in abundance in - for example – Mail reader comments to Inglis's story suggesting she was mother courage/a saint/etc. One thing that is very clear from the facts that are available is that her behaviour was far from saintly. The mob also includes unthinking knee-jerk responses to polls etc where an individual gives an of the cuff response without really thinking it through on yougov or say a telephone survey. And think it through we need to - as I said, this really is a matter of life and death. I should add that, given your consistently thoughtful posts, you do not fit my definition of a member of the mob!

I agree that those of sound and settled intent are free to determine their own fate. Indeed how could it be otherwise? I also agree that there is a real problem that arises from that position for those of sound and settled intent who lack the full means and/or ability to achieve their intent. It is not on to say of course you can kill yourself - and then ignore the practical side of it, because that is the suicide equivalent of saying you can have any colour you like, as long as it is black.

It may well be that as a society we have to accept that, if we accept the right to self-determination in those of sound mind and settled intent then we cannot accept it in one hand, so to speak, and take it away in the other, because in effect we thereby negate our acceptance.

The problem is how to get from that moral position to a practical expression of that position in the real world. Somehow, the idea of freelance or even employed non-medical executioners seems grim, even ghoulish - not to mention how such people would explain their occupation:

Scene: Social gathering (party, wedding, whatever):

1st person: Hi - what do you do for a living?

2nd person: I kill people.

Could be a bit of a conversation, err, killer...

The academics, medics and others who are arguing for more humane treatment at the end of life are by definition (because they have clearly thought long and hard, and are not giving a knee-jerk response) not part of the mob. In fact, I am a medic who argues for more humane treatment at the end of life too - we just differ in how we think that more humane treatment is best achieved.

The crux here is that the assumption here that protecting the vulnerable means others are as a result forced to endure inhumane degradations. We should be capable of both protecting the vulnerable and providing humane care. That is what palliative care is for; and I, for example, am quite satisfied that the doctrines of double effect, not striving officiously etc mean my hands are not unduly tied when it comes to providing effective humane care, whatever that care may require.

I think the semantics of the labels do in fact matter because that is how we distinguish between the different deeds, and their moral acceptability. Most of us appear to agree that suicide in those of sound mind and settled intent is acceptable. Many accept that it must follow that compassionate selfless assistance is acceptable. Some accept that there might be professional assisters. In all these cases, the deed is done by the individual, and so all these instances are instances of suicide.

However, where things start to get grey is when suicide moves from a private solo act to a joint endeavour. The crucial thing is the involvement of another, because that opens the door to influence by not only that other (which may often be benign, but cannot be guaranteed so), but also by the wider social wind that blows us to a position where suicide becomes more normalised. When all ones pals are lining up their KCl shots, then a pressure will be created to conform to that norm – and all the more so when the Warnocks of this world tell us it is indeed our duty to do so.

These then are the instances of suicide, where the hand that pulls the trigger (even if the gun was loaded by another) is that of the person who dies. The other (semantic) distinction is where the trigger is pulled by another - in the current context, what we call euthanasia, be it voluntary (the person wishes to be killed) of involuntary (the person doesn’t want to be killed, or has not expressed a view – as in Inglis).

So – where does this long rambling comment leave us? I suggest everyone (mob included) agrees that unnecessary suffering is intolerable and unacceptable. Where we differ is in the solution for the semantically different groups. Some thoughts:

1. DIY suicide in those of sound mind and settled intent: cannot, given the importance of self-determination, be anything but acceptable

2. Assisted suicide in those of sound mind and settled intent: an argument can be made that it is acceptable in an ideal world (because of (1) above); but highly (and so persuasively?) problematic in the real world because of (a) risks of undue influence and pressure to conform effects on those are not in fact of sound mind and settled intent and (b) practical problems of implementation

3. Active voluntary euthanasia in those of sound mind and settled intent: again, given (1) above, an ideal world case can be made that – providing executioners can be found – then it is actually very hard to argue against this; but again highly (and so persuasively?) problematic in the real world, for the same reasons as given in (2) above

4. Active involuntary euthanasia: never acceptable.

Finally, there is passive euthanasia (which in fact already blends with traditional medical ways) – from turning off the ventilator at one end, through withdrawing forced/parental sustenance, avoiding/stopping antibiotics etc, to declining heroic surgery at the other end. These situations have always been with us, and have conventionally been managed on a best interests/not striving officiously to keep alive/letting nature takes its course basis – with legal input when needed in complex cases – and I see no reason to change that state of affairs.

Dr No’s solution where assisted suicide and/or active euthanasia might otherwise beckon is – as always – gutsy principled effective palliative care. If the patient accidentally – by way of double effect - dies receiving that care – so be it. The last thing Dr No wants to do is to strive officiously to keep alive.

And lastly - he also read Illich as a medical student (and since) – and he agrees that there is always an important case to be made that doctors should not stay into matters that are not their business – just as, doctor that he is, he can also always see a case for them having a say when they should do so.

If there is one thing the majority of bioethicists hate it is the “slippery slope argument”. It is wrong, wrong, wrong and should not exist, they excitedly exclaim. Of course slippery slopes do exist and the argument is correct. The problem is you cannot predict if and when a slippery slope will emerge, and you can never know quite where it will lead.

I agree with much of your argument, but the notion that assisted dying would “set [us] on a skidpan of moral ice that, as night follows day, can only end in [Action T4]” is over egging it. However, even if we assume this to be an extremely remote possibility, it should raise some doubts within the pro-assisted dying lobby. For my part, having worked on geriatric wards in the 1970s, I can see a number of slopes of which most the pro-AD lobby have no experience or knowledge. They might not end in Action T4, but, given that care for the elderly and EMI has in many respects worsened in the last forty years, they are nonetheless pretty unpleasant descents.

Keith - I suspect, but don't know, that bioethicists hate the slippery slope argument because the evident existence of real world slippery slopes so weakens their darling deontology that we pretty much left with consequentialism, which as we know they detest with much the same vigour as they detest slippery slope arguments.

'Skidpans of moral ice etc' ending up in Action T4 may be over the top - or is it? The trouble is (as you point out) that these slippery slopes aren't sunlight blue runs that lead comfortably to the ristorante; they are as often as not icy black runs taken in the dead of night, that end we know not where…until after the event. Action T4 started out as the Gemeinnützige Stiftung für Heil- und Anstaltspflege – translated as the ‘Charitable Foundation for Cure and Institutional Care’ – hardly a toxic sounding combination – and yet the three Cs of charity, cure and care skidded and slipped over a few short years into the chilling reality of institutional euthanasia. The key point, it seems to Dr No, is that we do not know with foresight where a relaxation of the law on homicide will take us – and to him that means extreme caution, and a vigorous application of the precautionary principle, are more than amply justified.

Dr No notes with interest but not surprise that our good friend and sparring partner IB has been a-posting on McMargo’s Lead Balloon Bill. Interestingly but not surprisingly it explores the possible deniability of any overt and covert pressure created by a relaxation of the law on the vulnerable to agree, acquiesce or just not object to, an early exit.

At one point Mr Brassington remarks ‘I honestly can’t make sense of this’ which is commendably honest, but unnecessary. The remarks which he cannot make sense of – part of MSP McMahon’s contribution to the debate – are in fact perfectly clear, the gist being that a relaxation of the law will create a climate in which the common opening gambits of discussions about suicidality (‘have you thought life is not worth living’; ‘have you thought you would be better off dead’), previously always understood as anti-suicide in spirit, will, when an option to take the Warnock ticket exists, adopt an ambivalence; and that ambivalence will certainly allow, perhaps enable, and may even encourage some to take the early exit ticket they would otherwise not have taken.

I know a good number of consequentialists that adamantly reject the slippery slope argument (mainly when it does not suit their argument). After all, the real world should never get in the way of a theory.

I agree that we should always have an eye to history; for as you say, much of the horrors in Germany were by no means extreme in their beginnings. The so-called “human enhancement” theories of today worry me because of their distorted understanding of genetics and indeed most of science and technology; something they share with those terribly respectable and reasonable Victorian men of letters who first thought up eugenics when dear old Adolf was a bouncing baby. The possibility that human enhancement will lead to the gates of another Auschwitz might be extremely remote, but existential threats of this type cannot be ignored given the number of bouncing babies in the world.

Anyway I digress and make light of a serious problem. It’s much the same with AD. But even if the consequences were not so horrific, I am still left with the memory of elderly people saying they were a burden to their children and perhaps they would be better off dead. Warnock might agree but she did not know the people involved.

It has been raised many times that the idea of patients considering themselves “a burden” to their family or society is an argument for not introducing AD. It is difficult to see how this motive could be avoided.

In Oregon it’s said there is a strong culture of independence and this may relate to why their ”Death With Dignity Act” was passed albeit initially with a very small majority. It was considered that the Oregonians would have been unlikely to ballot in favour of voluntary euthanasia (perhaps this is also a reflection of their independence) and so in this U.S.A. state the “dignity” of dying is restricted to “assisted suicide” and as far as I can gather voluntary euthanasia is still illegal in Oregon. But there’s surely an overlap between “not being a burden” and being “fiercely independent.” It could be argued then, that Oregon accepts that it is neither distasteful nor unethical that people who feel they are likely to become a burden to society are helped to die for that reason.

I do not think the argument that a dying person must suffer the degradations of the final stages of a terrible illness in order to protect others as terribly convincing.

First Aid Kits (and A&E charge nurse from earlier) - Two thoughts:

1. Dr No believes it is a common fallacy that maintaining a position against assisted dying/suicide necessarily means others 'must suffer the degradations of the final stages of a terrible illness'. The doctrines of double effect, and of not striving officiously to keep alive mean that in the very great vast majority of cases, a patient can be kept comfortable, and life not wrongly preserved against the natural tide of nature taking its course.

2. The 'others might suffer' argument smacks somewhat of Lord Denning's infamous better to bang up an innocent few than have the legal system in disarray - so called 'noble cause corruption'. Of course dignified death is a noble cause - but it doesn't mean that we should kill a few innocents along the way.

"dignified death is a noble cause - but it doesn't mean that we should kill a few innocents along the way"

That's 'it' Dr No; the moral of the story!

If capital punishment was abolished for fear that some innocent individuals might lose their life for a crime they never committed, then it follows that AD must never be allowed to become legal on the same basis. Because you can never prove beyond doubt that the system, if legalised, won't be abused by some, hence innocent people may be 'killed' prematurelly and without their consent too! Then the killer claiming it was their wish long after they have gone - and you can do nothing about it then!

Legalising Assissted Dying hence should be resisted based on the same principales that abolished capital punishment long ago! More so with AD, because all the potential AD victims are suspected of no crime other than being ill, frail and/or old! Unfair!

This is all about where the burden of the law falls. In a sense, pro euthanasia campaigners are making the case for keeping the law as it is, because they say it would only apply to a few dozen people a year (that's what they said up in Scotland anyway.) If that is the case then why change? There isn't a law in the land that can cover all eventualities; that is why we have a judge, a jury and a prosecution service to deal with situations on a case by case basis. To give an example; a man goes into a shop and steals a loaf. He gets caught and when he is before the judge, it turns out he did it because he was poor and hungry. The judge lets him off with a warning. But what doesn't then happen is that the judge changes the law to say that stealing is ok, because in most cases it isn't. And he wouldn't either say that it was ok to steal as long as you were poor and hungry, because then you would have lawyers arguing about the definition of who was poor and if they came within a certain income bracket and how many calories you were meant to consume a day. It would become hopelessly confused. So it is with euthanasia. Once you start saying that its ok to kill certain classes of people because of illness or disability but not ok to do it to people who are physically healthy, you are introducing a value judgement and putting a price tag on someone. You are diminishing someone's protection under the law, however well meant that is. And there isn't a logical stopping point for that. When euthanasia started in the Netherlands, it too was only meant to be for people who were terminally ill. This March a petition with 100 000 signatures was handed into the Dutch parliament to force a debate. The subject? To allow people over the age of 70 who were healthy, but who considered their life 'complete' to be allowed to avail themselves of euthanasia. If we have any sense we will benefit from the Dutchs' misfortune and not go down this slippery slope.

"The doctrines of double effect, and of not striving officiously to keep alive mean that in the very great vast majority of cases, a patient can be kept comfortable, and life not wrongly preserved against the natural tide of nature taking its course" - in theory, maybe, but we all know that access to palliative care is hit and miss at best, and always has been?
http://www.bbc.co.uk/news/health-11902757

Isn't it only recently that some services have finally woken up to the fact that patients with heart failure and COPD have been dying ghastly deaths, simply because the disease they suffered with fell outside the cancer paradigm so was not deemed appropriate for effective palliation?
Some are now saying similar things about conditions like Alzheimers and other irreversible dementias which also inflict all manner of degradations in the final stages?

Anyway, this is not about the pros/cons of palliative care, even though access is likely to prove increasingly problematic as the number of oldies mushroom over the next few decades, but instead the application of a medical framework to what is fundamentally an existential problem, albeit one with a significant medical component.
Of course, those of a religious disposition are also terribly worried about any sort of undermining of the notion of "sanctity of life" since such a posture is expressly forbidden within their particular belief system.

Nonetheless, many secularists regard recognition and acceptance of a person's individual autonomy as one of the most important cornerstones of 'being' - for this group respect for autonomy, assuming capacity, just about trumps all other belief systems and there is a certain degree of resentment to the imposition of medical or religious values, however laudable these values might appear from a medical or religious perspective.

Most doctors do not want to intentionally end a person's life - I fully accept and understand that, but nowadays technology exists that could in theory allow such actions to be placed in the hands of non-medics if that is what we, as a society, decide is a viable option amongst those who prefer to opt out of enduring the endgame of a horrible and irreversible illness.

So we have been slowly drip by drip anaesthetized by propaganda and a vocal minority who believe they have the right to die when they want to, even if they become so disabled that they cannot themselves perform the act. Having written an AD and in some cases made their intention clear to the media, they can happily wait for someone else to kill them when they choose.

Snag 1 is that these people know that they will not wish to die until they are completely unable to carry out the task themselves, so their concern is that if a compassionate relative or friend does the act for them, but who having assisted, maay then face the prospect of prosecution for having assisted a suicide. So an alternative has been suggested and brought into legislation.

Doctors can do it.

No need to go to Switzerland.

Snag 2. What if I am not compus mentis? I do not wish to live if I have Dementia/Alzeimer's disease (even if I feel quite happy and don't know much about it and cannot remember if have written my AD?

The Doctor can do it in real time.

Snag 3

What if I go into hospital and I am not terminally ill with Dementia but I have got an infection?

Don't worry - you'll be even more confused with your infection and the Doctor will think that you are much more demented than you really are. You won't have to make a decision, the doctor will make it for you.

You will still not know a thing, and I doubt your relatives will either.

What if I don't have Dementia at all and I am just temporarily in a coma from a stroke or just confused?

The doctor may also be confused.

What if I am mentally ill?

Pass
______________________________

This legislation should never have reached the statute books. It should have been left to the individual doctors in individual cases who know their patient's needs and, when they know their patient well enough to know death is imminent. Their primary concern is then comfort, together with relief of pain and to inform relatives.

Doctors should not be asked to assist suicides. Their role should only be in treating a patient who is actually dying, not to put in train a protocol (such as the Liverpool Pathway) to bring on or hasten their death. People have a habit of dying in their own time, not someone else's.

I attended a Warnock lecture on the "Meaning of Life". Five minutes into the lecture I realised that it was all about getting rid of people who have dementia. Her thrust was that everyone should sign an advance directive to be put down by the medical profession when the disease became advanced. This should be done, she opined, on her premise that it was immoral of Alzheimer/Dementia sufferers to burden the NHS with the cost of looking after them.

Relatives may not be the only people exercising coercion.

Web: Doctors help One in Eight to die
Sentenced to death by the NHS

Perhaps Interwingler will be pleased that there is one less 'propagandist' to worry about?
http://www.jacquelinejencquel.com/post/nan-maitland-british-activist-end...

Nan Maitland said, "For some time, my life has consisted of more pain than pleasure and over the next months and years the pain will be more and the pleasure less. I have a great feeling of relief that I will have no further need to struggle through each day in dread of what further horrors may lie in wait. For many years, I have feared the long period of decline, sometimes called ‘prolonged dwindling’, that so many people unfortunately experience before they die. Please be happy for me that I have been able to escape from this, for me, unbearable future. I have had a wonderful life, and the great good fortune to die at a time of my own choosing, and in the good company of two FATE colleagues. With my death, on March 1st, I feel I am fully accepting the concept of ‘old age rational suicide’ which I have been very pleased to promote".

Just looking at the Oregon experience - or why Oregonians have forced the issue on 'a good death'?
It would appear 'loss of autonomy', 'decreasing ability to participate in activities that made life enjoyable', and 'loss of dignity' are the recurring, and enduring themes (so nothing to do with accessing palliative care, or bumping of demented grannies).
http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResea...

People who chose an assisted death tend to be white, aged between 65 and 84, often university educated, always terminally ill and almost always enrolled in palliative care.
http://www.guardian.co.uk/commentisfree/2010/mar/10/right-to-good-death