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Arguably a Long Shot

Posted by Dr No on 23 January 2012

close_call.jpgReporting on the latest DYI enthusiast headed for the English High Court, a New York newspaper describes – without irony – the legalise euthanasia bid as ‘arguably a long shot’. More close call, or perhaps even parting shot, it seems to Dr No: but then we are two nations separated by a common language.

The case concerns a fifty-seven year old man who finds his life intolerable after a stroke seven years ago left him with the locked-in syndrome. An active capable and intelligent man before his stroke, he now sums up his life as ‘dull, miserable, demeaning, undignified and intolerable’, and, understandably, wants out. Being, he says, unable to do the deed himself, he has applied to the Court for a declaration that any doctor – in passing, Dr No does not see why the application has been limited to doctors - terminating his life will have a ‘common law defence of necessity’ against any possible murder charge.

Dr No is not entirely persuaded that the man is incapable of taking his own life. He is said to have some head movement – which suggests he might be able to head-butt a switch to trigger a contraption rigged up to deliver the fatal dose; or failing that, he is able to use a computer, and it cannot be beyond the wit of man to devise an ‘exit programme’ that would achieve, as the ID would say, the same ‘result’. In these scenarios, although assisted, the death would be one of suicide, in that the act which triggered death would be done by the individual. And suicide is not illegal. The legal obstacles would be reduced to those of assisting suicide; there would be no need for a pre-emptive declaration to safeguard Dr Death.

Be that as it may, the case does raise a difficult question about the current ‘you can be killed anyway you want so long as it is suicide’ state of the law. Consider, for a moment, twin brothers, in their fifties, and both, on the very same day, suffer strokes, and are left with the locked-in syndrome. Before their strokes, both were active capable and intelligent men, and both, following their strokes, retain their intelligence and sensibility, and both find their life intolerable, and, after due consideration, want out. So far, their circumstances are identical, but there is one crucial difference. The first twin does indeed have the full locked-in syndrome, but the second, against all the odds, has regained the movement of his left thumb. Then place the twins at Dignitas, where assisted suicide is allowed. The second twin is able, by initiating the last act that will lead to death, to commit suicide; but the first cannot.

This, it seems to Dr No, is a very thorny question. It cannot be solved by insisting that the twin with the working thumb desist – for he is of sound mind and settled intent, and has every right to determine his own fate. But, at the same time, it seems intolerable that an accident of motor function should deprive the dud thumb twin, who in our example is in every other respect truly and fully identical to his twin, of the same right to determine his own fate.

Long shot or not, it is indeed a very close call. Dr No cannot for the life of him see what the answer might be.


"you can be killed anyway you want so long as it is suicide’ state of the law" - I see where you are coming from, Dr No but there are further nuances - going back to the recent Canadian study the following end of life scenarios are defined thus

“Withholding of potentially life-sustaining treatment” is the failure to start treatment that has the potential to sustain a person's life. An example is not providing cardiopulmonary resuscitation to a person having a cardiac arrest.

“Withdrawal of potentially life-sustaining treatment” is stopping treatment that has the potential to sustain a person's life. An example is the removal of a ventilator from a patient with a devastatingly severe head injury after a motorcycle accident with no prospect of improvement.

“Advance directives” are directions given by a competent individual concerning what and/or how and/or by whom decisions should be made in the event that, at some time in the future, the individual becomes incompetent to make health care decisions. An example is a woman who has signed a document that states that, should she fall into a persistent vegetative state, she does not wish to receive artificial hydration or nutrition.
Or, as another example, a man who has signed a document that states that, when he is incompetent, he wishes his wife to make all health care decisions on his behalf. There are two kinds of advance directives: instruction directives, which establish what and/or how health care decisions are to be made; and proxy directives, which establish who is to make health care decisions.

“Potentially life-shortening symptom relief” is suffering control medication given in amounts that may—but are not certain to—shorten a person’s life. An example is giving ever-increasing levels of morphine necessary to control an individual’s suffering from terminal cancer when themorphine is known to potentially depress respiration even to the point of causing death (but it is not known precisely how much is too much as the
levels are slowly increased).

“Palliative sedation” is an umbrella term used to explain intermittent and continuous as well as superficial and deep sedation. The most contested subtype of palliative sedation is known as “terminal sedation.”

“Terminal sedation” is potentially life-shortening deep and continuous sedation intentionally combined with the cessation of nutrition and hydration.

“Assisted suicide” is the act of intentionally killing oneself with the assistance of another. An example is a woman with advanced ALS who gets a prescription from her physician for barbiturates and uses the drugs to kill herself.

Voluntary Euthanasia” is an act undertaken by one person to kill another person whose life is no longer worth living to them in accordance with the wishes of that person. An example is a man bedridden with many of the consequences of a massive stroke whose physician, at his request, gives him a lethal injection of barbiturates and muscle relaxants.

Once we accept that some of the above are relatively common place we can already see that there is an established medical culture of shortening or ending life both here and, of course in places where euthanasia is permissible.

A&E CN - Dr No agrees it is important to be clear about definitions, and he is normally very fastidious about this, even if he was perhaps less so in this post.

The twins dilemma shows how the slippery slope can (will?) happen in practice. The argument goes like this:

Twin Bill (working thumb) has the right and ability to commit suicide, and so should be allowed to do so. However he lacks the equipment to do so, and so needs to be set up (assisted) to do so. So what would have otherwise been an autonomous suicide is now an assisted suicide.

Twin Ben (dud thumb) has an equal right to self determination but cannot exercise it because of a accident of nature. This is obviously and grossly unfair, and so he deserves that one additional step of assistance: someone else pushes the button for him. Twin Bill's assisted suicide has for Twin Ben now become voluntary euthanasia.

Across the way, another patient has the same will and determination to end his life as the two twins. Like Twin Bill, he has the motor ability to do so, but, despite his will and determination, he lacks the psychological robustness to push the button himself. But he is no less determined in his wish to die. So a kind and caring compassionate doctor steps forward, and pushes the button for him. Voluntary euthanasia has now been extended to those who, for whatever reason, will not or cannot do the deed themselves.

All these three cases are clearly voluntary, whether the process be assisted suicide or euthanasia. But what then of the 'squeezed volunteer'? He or she who, perhaps, volunteers out of a duty to others? Or the ageing relative 'squeezed' by children greedy for wealth? Is there really any practical way of blocking these grisly scenarios?

"Once we accept that some of the above are relatively common place we can already see that there is an established medical culture of shortening or ending life both here and, of course in places where euthanasia is permissible." Dr No is not sure that these practices are necessarily 'relatively common', or that there is 'an established medical culture of shortening or ending life' here (although the LCP, for example, is very possibly taking us in that direction). Dr No, and the vast majority of doctors he has worked with over the years, have followed a combination of letting nature take its course when it is right (and patients/relatives have a loud say in that) to do so, and Cloughs's (whether he meant it to apply to these circumstances or not, it still works very well): 'Thou shalt not kill, but need'st not strive officiously to keep alive'.

"Is there really any practical way of blocking these grisly scenarios?" - arguments against euthanasia arise from two main schools of thought - there is a moral argument about sanctity of life (which owes a great deal to religious teaching) then there is the notion that euthanasia might be OK so long as the death of one person does not result (however unwittingly) in the untimely death of another.

To some extent these arguments rely on a moral distinction between active and passive euthanasia.
In other words they think that it is acceptable to withhold treatment and allow a patient to die, but that it is never acceptable to kill a patient by a deliberate act. Some medical people like this idea. They think it allows them to provide a patient with the death they want without having to deal with the difficult moral problems they would face if they deliberately killed that person.
For others this distinction is nonsense, since stopping treatment is a deliberate act, and so is deciding not to carry out a particular treatment.

Personally I regard compassion as the single most important quality in the relationship between any health system and those patients who come into contact with it (notwithstanding the general goal of trying to cure one or two along the way) - for those who really believe compassion is the bedrock of caring for people it becomes increasingly difficult to to maintain a paternalistic posture once they reach their hour of greatest need, at least this is how it seems once we actually listen to what it is they are trying to tell us?

Re the interesting link above, it brings to mind the death of Kerrie Wooltorton. The legal aspect of acts and omissions was one of the important issues and it seemed impossible then to reach a consensus on this.

Assisted suicide / euthanasia is surely "A Wicked Problem" of the highest order and even disregarding the "sanctity of life argument" there remains the potential for much collateral damage.

Perhaps, to get a handle on the problem, the first important question that should start off the debate should be:

"Thou shalt not kill but needst not strive, officiously, to keep alive."
Arthur Hugh Clough (1819-1861)

Was Clough wrong?

Perhaps it is impossible to move on until this question has been answered.

Even if society considers Clough's statement still to be valid, perhaps the second question should then be:

Is today's society now so critical of paternalism, that doctors should no longer be the ones to make a decision about not striving officiously to keep alive?

"Was Clough wrong?" - no, Clough recognised that it is OK to let people die by acts of omission once an arbitrary threshold has been crossed, a threshold since it can never be specified that will vary from one doctor to the next (and nowadays may driven by mundane variables such as rates of bed occupancy in over subscribed NHS hospitals - albeit subconsciously).

"Is today's society now so critical of paternalism, that doctors should no longer be the ones to make a decision about not striving officiously to keep alive?" - in the nicest possible way, yes it is; autonomy should trump paternalism amongst capacitated individuals - admittedly there is a debate to be had, and sometimes a very complex debate before capacity can be determined, but as far as I know it is not an issue in the Tony Nicklison case.

"I have never before confessed that my happiest moments were in fact when I was told – 27 years apart – of the deaths of my parents. Let me explain .......... "

"Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.”

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