"Will I be the only doctor who considers resigning from the BMJ..."

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Letters to British Medical Journal's  EDITOR as follows: 

bulletAcquiescence corrupts Dutch doctors
bulletRole of depression ignored
bulletPredictions of outcomes can be wrong
bulletMore palliative care is needed.
bulletStay away from the slippery slope
bulletNatural and unnatural death
bulletUndermines patient autonomy
bulletDo not change existing law
bulletResponses to poll are telling
bulletAuthor's reply
bulletEuthanasia: Present law protects doctors and patients

 

EDITOR, Will I be the only doctor who considers resigning from the BMA [British Medical Assoc.]  in protest against the blatant pro-euthanasia stance of its main organ in recent weeks? Two articles [] and one editorial[] about euthanasia have been published in the BMJ, yet none mentions the House of Lords Select Committee's Report on Medical Ethics, with its unanimous recommendation that there should be no change in the law to permit euthanasia because it is uncontrollable and too open to abuse.[]Acquiescence corrupts Dutch doctors BMJ 1994;309:471 (13 August)

 
bulletAcquiescence corrupts Dutch doctors

EDITOR, - Will I be the only doctor who considers resigning from the BMA in protest against the blatant pro-euthanasia stance of its main organ in recent weeks? Two articles1,2 and one editorial3 about euthanasia have been published in the BMJ, yet none mentions the House of Lords Select Committee's Report on Medical Ethics, with its unanimous recommendation that there should be no change in the law to permit euthanasia because it is uncontrollable and too open to abuse.4:

We acknowledge that there are individual cases in which euthanasia may be seen by some to be appropriate. But individual cases cannot reasonably establish the foundation of a policy which would have such serious and widespread repercussions...We believe that the issue of euthanasia is one in which the interest of the individual cannot be separated from the interest of society as a whole.

The pro-euthanasia stance seems even more remarkable in the face of the collective view of the BMA expressed in its recent publication on medical ethics:

The BMA considers that whilst there are many cases where a doctor should accede to a request not to prolong the patient's life, a doctor should not actively intervene to end that life....In the BMA's view, liberalising the law on euthanasia would herald a serious and incalculable change in the ethos of medicine.5

I doubt therefore if I am alone in thinking it unacceptable that a Dutch professor of obstetrics and gynaecology should be allowed some 800 words to give further airing to one sided Dutch arguments for euthanasia.3 For those of us remote from the reality of Dutch euthanasia practice there seems little doubt that acquiescence in euthanasia in the Netherlands has had a corrupting effect on the medical profession there. The official Ministry of Justice and Ministry of Welfare, Public Health, and Culture's Euthanasia Survey Report reported that 27% of doctors admitted having carried out euthanasia on patients without any request (p 47, table 6.1) and 72% routinely falsified the death certificate after euthanasia (p 38, table 5.14). The published guidelines for euthanasia are shown to be often disregarded (p 39, table 5.15; p 52, table 6.8).6

R Twycross

 

  1. Ward BJ, Tate PA. Attitudes among NHS doctors to requests for euthanasia. BMJ 1994;308:1332-4. (21 May.) [Abstract/Free Full Text]
  2. Van der Wal G, Dillman RJM. Euthanasia in the Netherlands. BMJ 1994;308:1346-9. (21 May.) [Free Full Text]
  3. Heintz APM. Euthanasia: can be part of good terminal care. BMJ 1994;308:1656. (25 June.) [Free Full Text]
  4. Select Committee on Medical Ethics. Report. London: HMSO, 1994. (House of Lords paper 21-I.)
  5. British Medical Association. Medical ethics today. London: BMJ Publishing Group, 1993:147-79.
  6. Committee to Investigate Medical Practice Concerning Euthanasia. Medical decisions about the end of life. II. Euthanasia survey report. The Hague: Ministry of Justice and Ministry of Welfare, Public Health and Culture, 1991.

 
bulletRole of depression ignored

EDITOR, - The editorial on euthanasia by A P M Heintz1 and the personal view by Ray Morrison2 made me feel concerned that the role of depressive disorders is often ignored in people who request euthanasia or express the desire to die.

Depressive disorders occur in 11.5% of elderly patients hospitalised for medical reasons3 and in 12.4% of institutionalised elderly people.4 Heintz quotes Van der Maas and colleagues, who state that 23% of people requesting euthanasia express "tiredness of life."5 This symptom in itself would be highly suggestive of the possibility of a depressive disorder.

The first patient described by Morrison is "very much in his right mind...neither depressed or distressed." It is not clear whether this is Morrison's opinion or whether the patient had a formal psychiatric interview. I wonder if a better response by the nurse who asked the Reverend Morrison to see the patient would have been to ask a psychiatrist to see the patient.

Morrison states that patients who express a desire to die "may even be treated as if they were depressed. This is not helpful and violates the integrity of such patients." The correct approach is for these patients to be assessed by a psychiatrist, who can determine whether they are depressed or not. Not doing this violates the integrity of such patients by refusing them help which could allow them to spend the rest of their lives free from the mental anguish that depressive disorders cause.

P Madeley

 

  1. Heintz APM. Euthanasia: can be part of good terminal care. BMJ 1994;308:1656. (25 June.) [Free Full Text]
  2. Morrison R. Patient's sense of completion. BMJ 1994;308:1722. (25 June.) [Free Full Text]
  3. Koening HG, Meadow KG, Cohen JH, Blazer DG. Depression in elderly hospitalized patients with medical illness. Arch Intern Med 1988;148:1929-36. [Abstract]
  4. Parmalee PA, Katz IR, Lawton MP. Depression among institutionalized aged: assessment and prevalence estimation. J Geront Med Sci 1989;44:M22-9.
  5. Van der Maas PJ, van Delden JJM, Pijnenborg L, Looman CWN. Euthanasia and other medical decisions concerning the end of life. Lancet 1991;338:669-74.

 
bulletPredictions of outcomes can be wrong

EDITOR, - Several unsubstantiated assertions and an unsound conclusion make the editorial by A P M Heintz1 seriously misleading. Few would accept that "the backbone of ethics is respect for human life," and only those with an inadequate ability to reason and reflect would conclude that patients must be kept alive at all costs for as long as possible. Such a view is clearly untenable. It is the high importance rightly attached to individual autonomy (rather than merely human existence) which requires that the best medical evidence be supplied to those who wish to make their own judgement about receiving or rejecting treatment for life threatening illness. In our current state of knowledge, the best medical evidence only sometimes includes valid information about the likelihood of prolonging or shortening life. Doctors often overestimate their ability to predict the outcomes of treatment,2 and specifically there is no evidence that skilful symptom control is more likely to shorten rather than to prolong life.

Another of Heintz's dangerously false assertions is that euthanasia refers to acts intended to shorten the life of only those who are seriously ill and only at the patient's request. The evidence to refute this also comes from Holland, where "life terminating acts without explicit request" are well documented3 and where a recent judgement accepted that no physical illness of any sort is necessary to justify euthanasia.4

The unsound conclusion that a solid legal basis for euthanasia is required assumes that such a notion is practically possible. A wide ranging, expert and thorough review of the evidence recently concluded that it is not.5

J Gilbert

 

  1. Heintz APM. Euthanasia: can be part of good terminal care. BMJ 1994;308:1656. (25 June.) [Free Full Text]
  2. Smith R. The ethics of ignorance. J Med Ethics 1992;18: 117-9, 134.
  3. Pijnenborg L, van der Mass P, van Delden JJM, Lowman CWN. Life- terminating acts without explicit request of patient. Lancet 1993;341:1196-9. [Medline]
  4. Spanjer M. Mental suffering as justification for euthanasia in Netherlands. Lancet 1994;343:1630. [Medline]
  5. Select Committee on Medical Ethics. Report. London: HMSO, 1994. (House of Lords paper 21-I.)

 
bulletMore palliative care is needed.

EDITOR, - I disagree with A P M Heintz's view that euthanasia can be part of good terminal care.1 It is confusing and misleading to associate good terminal care with euthanasia, and the board of directors of the European Association for Palliative Care has made an unequivocal statement of its position.2 We are strongly opposed to the legalisation of euthanasia, which is both dangerous and unnecessary.

We believe that if the principles and practice of palliative care were more widely recognised and adopted in countries such as the Netherlands, attitudes such as those of Heintz would be much less prevalent. Palliative care aims at achieving "the best possible quality of life for patients and their families" by focusing on a patient's physical, psychosocial, and spiritual suffering.3 requests for euthanasia are far less common among patients who have access to special palliative care services than among patients without such access.

I believe that the legalisation of euthanasia would begin a slide into intolerable abuse, with burdensome patients being particularly vulnerable. We should maintain an uncompromising stand against a law that would permit the administration of death.

V Ventafridda

 

  1. Heintz APM. Euthanasia: can be part of good terminal care. BMJ 1994;308:1656. (25 June.) [Free Full Text]
  2. Roy DJ, Rapin C-H. Regarding euthanasia. European Journal of Palliative Care 1994;1:57-9.
  3. World Health Organisation. Cancer pain relief and palliative care. WHO Tech Rep Ser 1990:804.

 
bulletStay away from the slippery slope

EDITOR, - A P M Heintz tells us that to be for or against euthanasia "makes no sense."1 I disagree. I am against euthanasia as Heintz defines it: an act whose primary intention is to cause death.

Heintz is not talking about withholding aggressive treatment in certain circumstances or about giving adequate analgesia, both of which may on occasion speed death. These are legitimate and inevitable in the practice of many doctors. No: Heintz is advocating the deliberate ending of another person's life.

Shall we follow the Netherlands' example in this, as Heintz urges us to do? The Dutch government's criteria for euthanasia include the stipulation that the patient's request to die must be durable and consistent. Yet in 1990 in the Netherlands medical examiner Van de Waal found that the interval between the request for euthanasia and its implementation was less than 24 hours in 13% of cases and no more than one week in 35%.2

The Remmelink committee, set up by the Dutch minister of justice and the secretary of state for health to investigate euthanasia, reported in 1991.3 It found that in 1990 in the Netherlands 2300 officially recorded instances of euthanasia occurred. But, in addition, there were 1000 cases in which life was deliberately terminated without an explicit request from the patient.

Shall we embark on that slippery slope? Heintz advocates regulations to safeguard against the misuse of euthanasia. But the experience in the Netherlands is not encouraging, and there is little reason to believe that Britain would be any different.

If governments want people to be cured and treated and given palliative care then let them continue to employ doctors. If they want people to be killed then let them appoint executioners. I, for one, want no part in that.

H J Thomson

 

  1. Heintz APM. Euthanasia: can be part of good terminal care. BMJ 1994;308:1656. (25 June.) [Free Full Text]
  2. Chalmers G. Killing - by what authority? Journal of the Christian Medical Fellowship 1993;39:4-10.
  3. Van der Maas PJ, van Delden JJ, Pijnenborg L, Looman CW. Euthanasia and other medical decisions concerning the end of life. Lancet 1991;338:669-74.

 
bulletNatural and unnatural death

EDITOR, - The BMJ issue of 25 June contains several articles on our need to recognise the inevitability of natural death, which is not necessarily to be feared. Dominique Florin recognises that we do not need to try to resuscitate every patient after a cardiac arrest and explores how decisions about cardiopulmonary resuscitation should be made.1

In their contribution to the debate on withholding and withdrawing life sustaining treatment from elderly people Len Doyal and Daniel Wilsher make the extreme claim that the sentence "to exercise their rights patients must have some potential ability to formulate aims and beliefs and to choose to act accordingly" means that "without such potential, patients cannot be regarded as `persons' with any associated rights, including the right to lifesaving treatment."2 The philosophical presuppositions of this controversial view are not defended in the paper.

Hospital chaplain Ray Morrison would "like everyone to be able to echo the cry of Jesus which he made at the end of his life, `It is finished.' "3 Though this example is not one of natural death, it does represent finished business. Health care must recognise the reality and the rightness of natural death and of finished business.

In contrast is the editorial by A P M Heintz, advocating euthanasia.4 This is unnatural death and will lead to much unfinished business for our patients if Britain is unwise enough to follow the Dutch lead. How can Heintz possibly reconcile the statement that "the basic question is whether we accept the right of human beings to decide for themselves how their lives will end" with the Dutch government's statistic that in 1990, 0.8% of all deaths were due to "life terminating acts without explicit request"?5 Dutch doctors kill more than 1000 patients a year without gaining their consent. Heintz has quoted from the report that includes this statistic and presumably, therefore, is aware of it. The fact that Heintz chooses to ignore it makes a mockery of the rest of the editorial, which fails to show that euthanasia "can be part of good terminal care."

A Fergusson

 

  1. Florin D. Decisions about cardiopulmonary resuscitation. BMJ 1994;308:1653-4. (25 June.) [Free Full Text]
  2. Doyal L, Wilsher D. Withholding and and withdrawing life sustaining treatment from elderly people: towards formal guidelines. BMJ 1994;308:1689-92. (25 June.) [Free Full Text]
  3. Morrison R. Patients' sense of completion. BMJ 1994;308:1722. (25 June.) [Free Full Text]
  4. Heintz APM. Euthanasia: can be part of good terminal care. BMJ 1994;308:1656. (25 June.) [Free Full Text]
  5. Van der Maas PJ, van Delden JJM, Pijnenborg L, Looman CWN. Euthanasia and other medical decisions concerning the end of life. Lancet 1991;338:669-74.

 
bulletUndermines patient autonomy

EDITOR, - A more careful reading of the Remmelink report than that of A P M Heintz1 reveals that 3700 Dutch deaths in a single year occurred as a result of euthanasia (3300) and assisted suicide (400).2 This included 1000 patients whose doctors gave them "life ending treatment" without request.

It is difficult to see how this squares with Heintz's concern to "accept the right of human beings to decide for themselves how their lives will end." The House of Lords Select Committee on Medical Ethics unanimously rejected euthanasia,3 recognising that legalising the practice undermines patient autonomy.

The Royal Dutch Medical Association and the "Dutch Commission for the Acceptability of Life Terminating Action" (a specious euphemism) have recommended that it can be ethically acceptable to terminate the lives of those suffering from severe dementia. Earlier reports have approved similar action for comatose patients and severely handicapped neonates.4 It seems that Holland is moving rapidly down the slippery slope.

Leo Alexander, a psychiatrist who worked with the Office of the Chief Counsel for War Crimes at Nuremberg, described a similar transition of values in a 1949 paper which deserves much wider circulation: "The beginnings at first were merely a subtle shift in emphasis in the basic attitudes of the physicians. It started with the attitude, basic in the euthanasia movement that there is such a thing as a life not worthy to be lived. This attitude in the early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non- Germans."5

The Hippocratic Oath states, "I will give no deadly poison to anyone if asked, nor suggest such counsel." The BMJ would do well to promote ethics which have stood the test of time rather than granting editorial space to contemporary iconoclasts with short memories.

P Saunders

 

  1. Heintz APM. Euthanasia: can be part of good terminal care. BMJ 1994;308:1656. (25 June.) [Free Full Text]
  2. Gunning KF. Euthanasia. Lancet 1991;338:1010. [Medline]
  3. Select Committee on Medical Ethics. Report. London: HMSO, 1994. (House of Lords paper 21-I.)
  4. Hellema H. Dutch doctors support life termination in dementia. BMJ 1993;306:1364. [Medline]
  5. Alexander L. Medical science under dictatorship. N Engl J Med 1949;241:39-47.

 
bulletDo not change existing law

EDITOR, - It is surprising that, after the extensive and informed debate in Britain over the past 18 months, the BMJ has decided to publish an article from a Dutch obstetrician as an editorial on terminal care.1

In 1993 the House of Lords convened a Select Committee on Medical Ethics to look at issues surrounding ethical decisions at the end of life, including euthanasia. Evidence was sought widely and was received in writing and orally from various groups and professional bodies, including the BMA, pro-euthanasia groups, and the hospice movement.

The Association for Palliative Medicine, whose members in hospitals, hospices, and the community work daily with patients facing death, stated that "persistent rational requests for euthanasia are extremely rare. The potential for misinterpretation, hasty inappropriate action, pressure on the vulnerable, and straightforward abuse is such that the direct intentional killing of a person at their request should remain illegal."2

The select committee also visited the Netherlands, where specialist palliative care services are less well developed than in Britain. They returned "feeling uncomfortable, especially in the light of evidence indicating that non-voluntary euthanasia - that is to say, without the specific consent of the individual - was commonly performed," and they concluded that "it would be virtually impossible to ensure that all acts of euthanasia were truly voluntary and that any liberalisation of the law in the United Kingdom could not be abused." They were "also concerned that vulnerable people - the elderly, lonely, sick or distressed - would feel pressure, whether real or imagined, to request early death."3

The Dutch Physicians' League has become increasingly concerned about events in its own country. The outcome of the judgment on Dr Chabot in the Netherlands shows that abuse of the Dutch guidelines is already being sanctioned. The BMA, in its authoritative text Medical Ethics Today4 and in its evidence to the select committee, stated the dangers of the "slippery slope": by removing legal barriers to the previously unthinkable and permitting people to be killed, society would open up new possibilities of action."5 The BMA opposes the legalisation of voluntary euthanasia.

The select committee's considered and unanimous conclusion was to "recommend that there should be no change in the law to permit euthanasia."5

I G Finlay

 

  1. Heintz APM. Euthanasia: can be part of good terminal care. BMJ 1994;308:1656. (25 June.) [Free Full Text]
  2. Association of Palliative Medicine. Submission from the ethics group of the Association for Palliative Medicine to the Select Committee of the House of Lords on Medical Ethics. Southampton: APM, 1993:21.
  3. Walton J. Medical ethics select committee report. House of Lords Official Report (Hansard) 1994 May 9;554:1344-5. (No 83.)
  4. British Medical Association. Cessation of treatment and euthanasia. In: Medical ethics today. London: BMJ Publishing Group, 1993:175-7.
  5. Select Committee on Medical Ethics. Report. London: HMSO, 1994: para 106, 237. (House of Lords paper 21-I.)

 
bulletResponses to poll are telling

EDITOR, - The MORI poll on euthanasia commissioned by the World Federation of Doctors who Respect Human Life in 1987, quoted by Tim Helme, was even more telling than he suggests.1 It revealed widespread ignorance about the possibility of pain control.

A total of 1808 people were asked, "In how many cases would you say that a person who is terminally ill could be almost totally free of pain through the use of drugs?" The answers were: in all cases, 9%; in most cases, 41%; in about half the cases, 14%; in a few cases, 20%; in no cases, 4%; don't know, 13%. These replies shed some light on the 49% support for the proposition (given in full by Helme1 that "Euthanasia should be made legal only when a patient who requests it is suffering from a severe illness and is in a lot of pain." There was 71% agreement with the statement, "If euthanasia was available on request to patients who are permanently dependent on others for medical or nursing care, some would choose it so as not to be a burden to others."

In a sample of 849 respondents, 59% agreed with the statement: "If euthanasia was practised in Britain, more elderly people would be afraid to go into hospital."

We would be glad to supply all the replies to this poll to any interested reader.

P Norris

 

  1. Helme T. Euthanasia. BMJ 1994;309:52-3. (2 July.) [Free Full Text]

 
bulletAuthor's reply

EDITOR, - Anne Rodway mistakes both the purpose and results of our paper on euthanasia.1,2 She criticises the "imprecise definitions" used in the survey. Although precise definitions of active or passive euthanasia are indeed important in moral discussion and in law, they are less vital within the confines of our survey. The questionnaire used was phrased in simple language, asking, for example, "In the course of your medical practice, has a patient ever asked you to hasten his or her death?" In this way, we hoped to be as confident as possible that each doctor surveyed understood exactly what each question was asking. It was not an ethical or philosophical discussion, but an attempt to find out what doctors actually do.

Rodway further reproaches us for addressing only doctors' difficulties. We had neither the intention nor the means of investigating attitudes in the general population or in other health workers, relevant as these attitudes may be. The paper's title clearly set its scope, and we drew no conclusions beyond these limits. It seems unfair to be criticised for not undertaking a different piece of research.

We disagree with Kenneth Collins and colleagues, who suggest that, in view of their results, Scots law with regard to euthanasia is "not unsatisfactory."3 From their survey, it would seem that some 40% of their Glasgow respondents had received a request for euthanasia in the past three years. Whatever the actual percentages, some patients do ask for, and some doctors do provide, assistance in shortening life. For these patients and these doctors the law is clearly unsatisfactory, and furthermore restricts open discussion on both a professional and personal level.

B Ward, P Tate 

 

  1. Rodway A. Euthanasia. BMJ 1994;309:52. (2 July.) [Free Full Text]
  2. Ward BJ, Tate PA. Attitudes among NHS doctors to requests for euthanasia. BMJ 1994;308:1332-4. (21 May.) [Abstract/Free Full Text]
  3. Collins K, Gilhooly MLM, Murray K. Euthanasia. BMJ 1994;309:52. (2 July.) [Free Full Text]

Letters

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Euthanasia: Present law protects doctors and patients

EDITOR, - A P M Heintz raises important issues in his editorial.1 He correctly distinguishes euthanasia ("a medical act that deliberately shortens the life of a seriously ill patient at his or her request") from the perfectly legal withdrawal or withholding of burdensome and unavailing treatments which only prolong or add to suffering. The recent recommendations of the Select Committee of the House of Lords2 uphold the rights of patients to refuse treatments which they do not wish to undergo, and urge the importance of doctors continuing to balance burdensomeness against benefit when advising on treatment.

The present law protects both doctor and patient. The patient feels that life is no longer worth living, but the moral stance behind the law reflects that a person's life is valuable per se - not because of what the person contributes or does, but because the person is a person. In rejecting legalisation of euthanasia, British society and its doctors are declaring the importance of protecting the weak, the disabled, and the dying - and in so doing declaring the dignity of human life. The Select Committee has pointed out that this demands increasing research and facilities for the care of such people.

Unfortunately the Dutch figures3 confirm that when voluntary euthanasia becomes ethically acceptable to the limited extent that it is in Holland, non-voluntary euthanasia is an inevitable accompaniment. Van der Wal and Dillmann acknowledge that the 1990 figures report more than 1000 occasions of non-voluntary euthanasia - when someone decided that another person's life was not worth living.4 So much for autonomy.

Lord Walton reflected on this in his speech to the House of Lords on 9 May 1994 when he said: "One compelling reason underlying this conclusion was that we do not think it is possible to set secure limits on voluntary euthanasia. As our report shows, we took account of the present situation in the Netherlands; indeed some of us visited that country and talked to doctors, lawyers and others. While we accept the sincerity of those who fervently advocated the present procedures that exist there...we returned from our visit feeling uncomfortable, especially in the light of evidence indicating that non-voluntary euthanasia - that is to say, without the specific consent of the individual - was commonly performed in Holland, admittedly in incompetent, terminally ill patients ... We concluded that it would be virtually impossible to ensure that all acts of euthanasia were truly voluntary and that any liberalisation of the law in the United Kingdom could not be abused. We were also concerned that vulnerable people - the elderly, lonely, sick, or distressed - would feel pressure, whether real or imagined, to request early death."5

These were some of the considerations which brought the BMA in recent discussions, the Select Committee, the Lords in debate, and the government to reject legalisation of euthanasia.

A M Smith

 

  1. Heintz APM. Euthanasia: can be part of good terminal care. BMJ 1994;308:1656. (25 June.) [Free Full Text]
  2. Select Committee on Medical Ethics. Report. London: HMSO 1994.
  3. Van der Mass PJ, van Delden WM, Pijnenborg L, Looman CWN. Euthanasia and other medical decisions concerning the end of life. Lancet 1991;338:669-74.
  4. Van der Wal G, Dillman RJM. Euthanasia in the Netherlands. BMJ 1994;308:1346-9. [Free Full Text]
  5. Lord Walton of Detchant. Medical ethics: select committee report. House of Commons Official Report. (Hansard) 1994; May 9:1345.

 

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