Dying to end the pain

Published on Sunday 29 January 2006 01:39

HAS there ever been a more powerful advocate for the legalisation of assisted suicide than Anne Turner? A retired doctor who had watched her husband die of a degenerative disease, she was both informed about her own condition, and articulate enough to make a compelling case for her right to die.

If everyone was like Dr Turner, it would be difficult to defend a law that denies terminally ill patients the right to exercise the same control over their deaths as they do over their lives.

After all, the religious/philosophical case against allowing assisted suicide has become ever more tenuous as science has progressed. Once it was possible to argue that life was a gift which should be taken away only by the Creator. Or that no physician should be placed in a position where he or she is implicated in a patient's death.

But as medical advances have prolonged life beyond its natural span, dying has become an increasingly protracted experience, subject to a mass of external influences, which could be seen as interfering with the plans of the Almighty.

Doctors and NHS Trusts are charged with making life and death decisions for us every day: they choose which patient gets the heart transplant or whether potentially life-saving drugs such as Herceptin should be provided on the NHS. Sometimes their intervention is more direct. Indeed, according to recent research, the lives of an estimated 3,000 patients were illegally terminated by doctors in the UK last year alone. Wouldn't it be better if these cases were open to public scrutiny, instead of being performed in an atmosphere of secrecy and fear?

Equally, patients routinely take decisions which impact on the length of time they live: to have or not to have chemotherapy, to have a Do Not Resuscitate order put on their file or to receive potentially life-threatening doses of pain-relieving morphine. It seems to me there is only a fine line between opting to refuse a treatment that may extend your life, and deciding to end it yourself.

Of course, no one is suggesting that those with lingering religious qualms (either patients or doctors) should be forced to get involved in assisted suicide. But equally, in an increasingly secular society, why should those who do not believe in God (Turner was a humanist) be held to ransom by adherents of any faith?

The problem with assisted suicide and euthanasia then lies less in the ethics of allowing a third party to help a terminally ill patient end their own life, but in the nitty gritty of devising a legal system that simultaneously allows those of sound mind to take an informed decision and protects the vulnerable from outside pressures.

This balance certainly does not appear to have been struck in other parts of the world where assisted suicide or euthanasia is sanctioned.

Let's take Oregon, where more than 200 people have opted for assisted suicide since it became the only US state to legalise it seven years ago.

There, patients may apply for assisted suicide if they are terminally ill with a prognosis of less than six months to live. They do not have to be in pain, there is no requirement for a psychological evaluation and only a small proportion are referred. Surveys on motivation suggest a significant proportion of those who request assisted suicide fear becoming a burden to their families. For poorer people, even more sinister factors may come into play, not least the fact that assisted suicide is available on Medicaid (limited federal and state-funded healthcare), where many other treatments they may need are not.

In Holland, where assisted suicide and euthanasia have been openly practised since the 1970s, you don't even have to be terminally ill to request assisted suicide. All you have to do is to prove you have suffered "unacceptable pain" over a protracted period and that there is no realistic prospect of your condition improving.

Nor does the pain have to be physical. In a controversial case in the mid-1990s, a doctor helped a woman mourning both her sons to die, just four months after the second had succumbed to cancer.

The most worrying aspect of the Dutch experience, however, is how easily euthanasia has gone from being a last resort to virtually routine. According to the United Nations, guidelines meant to restrict the practice are consistently breached, to the extent that many doctors admit to having ended the lives of patients who have not "explicitly" requested that they do so.

A report in the Dutch Journal of Medicine also reported that more than 20 babies suffering from conditions such as extreme spina bifida had been given lethal injections. Some claim that hand in hand with the normalisation of euthanasia in both Holland and Oregon has gone a failure to invest in palliative care or to teach GPs what pain relief is available.

All this is important because most people are not as informed and self-assured as Dr Turner. Faced with the prospect of a terminal or degenerative illness, they are angry, bewildered and unsure whether or not they can cope with what the future holds. If no attempt is made to answer their questions and address their fears, and they are offered no prospect of their pain being alleviated, they may choose assisted suicide by default.

Even if we accept the right to die in principle, then the question remains: how do we devise a law sophisticated enough to ensure the patient's confusion is not exploited either wittingly or unwittingly by those around them? How do we equip those charged with overseeing it to make decisions on difficult cases, such as a patient with a history of severe depression that pre-exists their terminal illness, or distinguish between the torment of a patient and that of a patient's family? How do we make sure that assisted suicide centres sit alongside hospices rather than replacing them? Only once those dilemmas have been resolved, should we even begin to think about legalising either assisted suicide or euthanasia in this country.

In the meantime, we would be better to concentrate on helping the terminally ill to come to terms with their condition, and to live fulfilling and pain-free lives surrounded by their loved ones - an aim cherished by Dame Cicely Saunders, the founder of the hospice service.

Then perhaps fewer people would see the need for assisted suicide and more would realise her definition of a good death: one where "as the body becomes weaker, so the spirit becomes stronger".