Society for Old Age Rational Suicide

There are basically four ways in which a doctor may help someone to die. The first, once called “passive euthanasia”, involves the withholding or withdrawing of medical treatment which is perhaps required to keep someone alive. This is completely legal because it is everybody's right to refuse medical treatment.

If someone is conscious, and is mentally competent, refusing treatment is straightforward. However, it is very important for all competent adults to complete a LIVING WILL (also known today as an ADVANCE DECISION), in which they can state the type of medical care they would wish to receive if they should become so ill or severely disabled that they cannot speak for themselves. Today, such documents are sometimes called “pro-choice” because they can allow individuals either to refuse further treatment, which would prolong their lives, or to request being kept alive for as long as possible, subject to medical consent.

Advance decisions offer an important layer of protection, legally documenting (since 2000, in Scotland, due to the Adults with Incapacity Act; and since 2007, in England and Wales, because of the Mental Capacity Act) an individual’s choices, and sometimes tipping the scales when there is debate or confusion about what to do. Thus, they can be of considerable benefit to one’s family - relieving them of the burden of responsibility about what a relative wants (possibly avoiding potential family disagreements) - as well as to the doctors involved at the end of a person’s life. In addition, in an advance decision, an adult can name a health care proxy (a relative or very close friend) who can explain someone’s wishes and expectations if these are unclear in the advance decision.

Living wills or advance decisions allow us to take responsibility for our medical care right up to the end. Furthermore, it is important to stress that these documents are fully supported by the British Medical Association, the General Medical Council (which issued further guidelines in 2009 stressing again that doctors must respect their patients’ last wishes regarding final medical treatment), the Royal College of Nursing, and the Law Society. In the UK, the main organizations providing advance decision documents are Compassion in Dying, in London, and Friends At The End, in Glasgow (for further information, please see the “Useful Links” section of this website).

The second way in which a doctor can assist someone to die is through the process, once known as the “double effect”, but now more honestly called “TERMINAL SEDATION” or “CONTINUOUS DEEP SEDATION”. When someone is suffering from the effects of a terminal illness, a doctor can use sedatives and painkillers (like diamorphine) to “lessen the pain and/or distress”. Officially, a palliative care doctor will prescribe these drugs in dosages which are necessary to keep the patient symptom-free. But, a more compassionate doctor can give increasing amounts of such drugs, privately knowing that the intention is to shorten the patient’s life.

A good example of double effect was demonstrated in the High Court case (in London) of Annie Lindsell in 1997. She had motor neuron disease, and had written a living will refusing tube feeding, if this became necessary to keep her alive. In 1997, she sought a court declaration that her GP could administer enough diamorphine to render her unconscious when her ability to swallow food normally became affected. In the High Court, her doctor stated that “I believe in the forthright and unhesitating relief of distress and pain, with no half measures…I am going to treat Annie when she develops symptoms which prevent her from eating and drinking. This will allow her to sleep. There will be no eating and drinking. The decline into death is quite predictable”. The High Court confirmed this approach, thus approving of continuous deep sedation or what is really “slow euthanasia”.

Having a carefully-written Advance Decision, regarding specific wishes on the type of treatment that an individual would like to receive, when particular painful or distressing symptoms of an illness might appear (even going so far as requiring aggressive palliative care, such as Terminal Sedation), can be very reassuring for many as they enter the “very elderly” stage of their lives.

Thirdly, a doctor can help a terminally-ill patient, or someone suffering unbearably from a severe chronic illness, with an ASSISTED SUICIDE. The doctor can either write a prescription for a lethal substance or perhaps even provide the actual drug. This possibility is illegal in the UK. But, it is legal in the American states of Oregon and Washington, and also in Luxembourg, and The Netherlands, and is decriminalized in Switzerland. In these places, there are strict guidelines, and the system works well, without any abuse, supported by the local populations and a majority of doctors. Also, it is generally agreed that doctor-assisted suicide legislation does not compromise the development or easy access to palliative care, or the important patient-doctor relationship.

Finally, the fourth way for a doctor to end a patient’s life is by EUTHANASIA when a lethal drug is injected: this can be either non-voluntary or voluntary (in the latter situation, the patient has given permission for this procedure to happen). This is illegal in the UK. The best example of non-voluntary euthanasia in this country is the death of King George V in 1936. The king was dying slowly and he was semi-conscious on his last day. Without his knowledge, his doctor, Lord Dawson, consulted Queen Mary and her sons before he injected morphine and cocaine into the royal jugular vein. Later that year, in a debate in the House of Lords regarding a possible bill to legalize euthanasia, Lord Dawson stated that there was “no need to change the law as all good doctors do it”. Voluntary euthanasia today is legal in Belgium, Luxembourg and The Netherlands. As with doctor-assisted suicide, there are strict guidelines to be followed. Governmental reports on what is happening are regularly issued. About three per cent of all deaths in The Netherlands (where voluntary euthanasia has been possible since 1981) occur this way.

It is generally believed that British doctors would prefer a law allowing doctor-assisted suicide to one permitting voluntary euthanasia. There are two main reasons for believing this: firstly, as the patient is actively involved, in having to actually swallow the lethal substance, this reduces any concerns that it is not what the individual wants; and secondly, doctors are not directly ending a life, but merely providing someone with the opportunity to do so.

Until a 2004 survey was made by Professor Clive Seale, of London University, no one knew how often doctor-assisted dying occurred in the UK. Reporting in the January 2006 issue of Palliative Medicine, he estimated that one-sixth of all the deaths in this country were actually hastened by the intended, compassionate use of the “double effect”. But, rather surprisingly, he believed that there were also one thousand cases of voluntary euthanasia and two thousand deaths, due to non-voluntary euthanasia, occurring annually. Similar results were also obtained by Professor Seale in a follow-up study he made in 2007-08 which was reported in Palliative Medicine in 2009: then, he noted that “continuous deep sedation is relatively common in UK medical practice, particularly in hospitals and home care settings”.

In the UK, there have been ten attempts since 1936 in Parliament (at Westminster and in Edinburgh) to change the law to legalize either voluntary euthanasia or doctor-assisted suicide: unfortunately, in spite of popular support now in the region of 75 per cent, these efforts have been unsuccessful. It is vital that what is possible in Europe and in the United States today is carefully and impartially regularly reviewed. Then, we should ask ourselves, if legalized doctor-assisted suicide and voluntary euthanasia can work well in these places, why not in the UK? Are we, in this country, so different from the Belgians, the Dutch, the Luxembourgers, the Swiss, or those who live in Oregon or Washington State?

General medical opinion has been divided on the need for legislation for doctor-assisted dying. Back in 1996, a BMA News Review survey of 750 doctors revealed a 50/50 split. At the BMA annual conference in 2005, a neutral position was officially adopted, only to be reversed to the previous negative stance in 2006 after a vigorous campaign led by the Christian Medical Fellowship. In 2009, the Royal College of Nursing also decided to be neutral on this issue.