The Case for Voluntary Euthanasia
Contemporary Review, 219, August 1971
Considering that we all have to die one day, it is surprising that we do not make more effort to choose a time to suit ourselves, rather than leave such an important matter to chance, or to exhausted nature, or to the decisions of others. There is an inertia in living, which tends to keep the life process going until the difficulties become insurmountable. Doctors know that most patients shy away from death and, however uncomfortable their life, would rather die tomorrow than today. Such is their respect for this primitive urge that doctors have now made an ethical principle out of it.
It was not always so. Medical ethics, despite the conservatism of tb profession, change steadily with time; and they are different no in this respect from what they were when I was a young housema rather more than 40 years ago. Then there was not very much one could do to keep life going in the moribund patient; and it was considered wise and humane to let the dying patient slip away without trying to hold him back. Nowadays the profession has such powers to arrest the process of dying that it is difficult to leave the unused. In 1969 the Representative Body of the British Medic Association, in a strong condemnation of euthanasia, affirmed th 'fundamental objects of the medical profession as the relief o suffering and the preservation of life'. The preservation of life has, in fact, been made officially into a cardinal principle, although there is certainly a considerable number of doctors who would not agree with this unreservedly, and despite the many difficulties which this principle creates now that medicine has become what it is.
The official view gave the first priority to the prevention of suffering, but the order is frequently reversed. There are many conditions in which the preservation of life can only be bought by the prolongation of suffering. Doctors, especially the energetic teams of doctors and nurses in hospitals, can appreciate the preservation of life as a clear directive; and the measures it will call for will be plain enough. The prevention of suffering is a much more nebulous aim, and it is difficult to see how far one is successful in providing it. So the straightforward thing to do is to keep life going at any cost, and then do what one can to relieve the suffering entailed. The result is that there is a very great deal of most uncomfortable dying. Estimates by family doctors and other doctors of great experience vary between 5 and 15 per cent of cases in which there is serious or prolonged distress and suffering. It is possible to control pain in very painful conditions, but only by close and unremitting attention; injections, for instance, have to be repeated at short intervals. This is not generally a working practice in hospitals, except in special units; and it is rarely possible at home. But there are other distresses besides pain; and it is much more difficult to relieve nausea, difficulty in breathing, and the feeling of being wretchedly feeble and ill. It is quite common for circumstances to arise in which the doctor has to choose between the preservation of life and the relief of suffering, since the suffering can only end with the end of life. These are the situations in which, as some of us believe, it would be natural and right for the patient's own wishes to be consulted and obeyed.
Wherever they can, doctors avoid talking to their patients about their life expectation, or of death in any personal application. The subject lies under a kind of taboo. This is felt so much by patients that, when at last they become aware that they might be dying, they still feel it is impossible to ask their doctor whether this is so or not. If they are given the chance to talk about it, they will often seize it with gratitude and relief. Doctors then find, to their surprise, that there are many patients, particularly among the elderly, in whom the life‑urge has burnt itself out, and who would be glad to die. In two combined National Opinion Polls, 1964 and 1965, each of 1,000 general practitioners taken at random from the Medical Register, nearly half (48.6 per cent) of those who replied answered 'yes' to the question: 'Have you ever been asked by a dying patient to give him or her final release from suffering which was felt to be intolerable?' If the request were a legal one, would there be any humane grounds for refusing it? This is the direction in which lay, if not medical, opinion is tending to veer, for instance, the informed and sensitive opinion of the priest. The Archbishop of Canterbury, Dr. Ramsay, when asked how he felt about euthanasia, said: 'We need some more Christian exploration on this. I would say that where a patient is lingering on in great distress, without any possibility of continuing life or happiness or purpose, it is not necessary for the doctor to continue keeping him alive' (The Times, 3.5.71).
The preservation‑of‑life principle can be taken to lengths which are patently absurd. Two examples can be given out of the many that might be thought of. One is provided by the young man who suffers a severe head injury in a road accident. He is taken into hospital unconscious, and remains unconscious though still not quite dead, since his heart is kept beating with electronic aid and he still breathes with assisted respiration. The brain is shocked to begin with, so that one cannot tell how much brain tissue has been destroyed and how much put temporarily out of action, leaving recovery still possible. The greater the amount of tissue destruction, the longer unconsciousness is likely to last; and one can argue back from the duration of unconsciousness to the degree of recovery that can be expected. More exact information is available in the electrical output of the brain, which is traced in wave form by the electroencephalograph. It is still possible, even after some weeks of unconsciousness, for a man to recover and after months of convalescence regain a fairly normal life, though there will be some personality changes. If unconsciousness persists longer and longer, the chance of worthwhile recovery recedes. The state becomes a vegetative one, keeping going without electronic aid or artificial feeding. The heart beats; the chest breathes; bladder and bowels automatically empty themselves from time to time; food carefully spooned into the mouth calls w the swallowing reflex. But the patient is in a deep sleep, from whic he cannot be roused; great areas of the brain, on which awarenes depends, have gone for ever. It is our practice to keep patients alive i this state for as long as we can, for five years, six years and more, ii fact for years after the last hope has gone that they will ever b conscious again. No one supposes that the hospital is rendering am service to the unconscious man, for whom life and death haw equally ceased to exist. Nor could one claim that any service is don'; to the family. Relatives, and parents especially, will go on hopinc and hoping, however unreasonably, in a state so painful that, wher death finally does come, it is felt as a relief. Least of all has any service been rendered to society. The burden on the community is quite a heavy one. The nursing of such an unconscious patient makes a considerable demand on the hospital's resources; and the consequence is that medical aid to other patients must be denied or delayed. The reason for so much care and devotion so uselessly expended is that any other course is felt to be morally indefensible. The spark of life needs constant support: the monitoring of vegetative functions, antibiotics, special feeding, cleaning, care, protection, etc. Withhold it, and it dies. To withdraw it, then, is to kill; and for those who have dedicated themselves to the preservation of life, killing is unthinkable.
At the other end of life doctors are faced with an equivalent dilemma, and one which is now becoming extremely common. This is the problem of the very old. People start to age not all at the same time, and not all at an equal rate. Different tissues of the body have their own times for getting old, so that muscles, bones and joints, the arteries and the heart, the eyes and the hearing and the nervous system are not equally old at the same time; and here too there are wide differences between individuals. As time goes on into the seventies and the eighties, small incapacities and disabilities gradually accumulate. Life becomes more and more restricted, and even the restricted life becomes more and more difficult. Very often there is very little money to spare, or even downright poverty. Still more often there is great loneliness. Nowadays old people are no longer part of the nuclear family. Their children, with husbands or wives and children of their own, have no room for them in their homes, or in their lives. The world moves on with bewildering rapidity, and every new social change comes as an added strain. Then perhaps comes illness or an accident; the old person is taken into hospital, and soon transferred to a geriatric ward. Here he gets the best attention, and what is possible is done to put him right and make him able to look after himself again; then he can go home, perhaps with yet another minor disability; or into an old persons' home; or into a chronic ward where he can wait for death. These old people are very tenacious of life, and often get a lot of enjoyment and interest out of pitifully limited existences. But even then, as doctors who work in geriatric wards know well, about one in five of these patients will tell you if you ask them‑or even listen to them‑that they would very much like to be dead and done with it all, if only that were possible.
The most pathetic state is that of the old person whose brain ages faster than the other organs, so that he or she (it is usually she, since women live longer than men) becomes mentally senile. Experts have estimated that, by the age of 80, about one in 40 people can expect the onset of senile dementia. This is a hateful condition, degrading and slow to kill. Thirty years ago or so, before the discovery of antibiotics, the senile patient usually died quickly, since his resistance was so low and he was very liable to infections which were deadly in that enfeebled state. Pneumonia was 'the old man's friend' and, once it came, snuffed out existence in a day or so. Now our drugs are so powerful that the old man's friend is kept from the door when he calls. Protected against accidents and all causes of quick death in a well‑run hospital ward, the senile patient goes on into a state in which all mental faculties wither away, memory, intelligence, interest, understanding and judgment, love and affection, even the realisation of where one is, and the recollection of who one is. The final state is one of mindlessness. The shrivelled patient sits in bed with dull gaze and fingers plucking the bedclothes, unresponsive when spoken to, unnoticing of doctors, nurses, visitors, family, passively receiving the administration of food, the unremitting cleaning and care. An infection can run through such a ward like a Black Death, so that special precautions and the free use of antibiotics are needed; but with their aid these helpless bodies linger on for one year, two years and more. The excellent doctors and the devoted nurses (always too few for the great strain the work imposes) will say that this is right, and that this is not an undignified end. But surely there are few who would not dread it for themselves.
There are, of course, many last illnesses in which death can still come quickly and irresistibly; but the increasing powers of the doctors are closing these exits. More and more, patients are shown the way to a slower death, drifting downwards by infinitesimal stages into extreme debility, physical or mental or both. The long process is not easy, and often involves much suffering and distress. What we need is a means by which the private individual can exercise some selfdetermination. When the course is irretrievably downwards, the alternative to drifting is a quicker plunge, which must be by a voluntary act. What avenues are open today?
Since the Suicide Act of 1961, suicide in this country has not been an offence under the law. However, it is a long‑standing and persistent medical tradition to regard it as abnormal, usually the act of a mentally sick man, indeed itself constituting strong prima facie evidence of mental illness. Doctors think it their duty to interrupt a suicide, at any moment however late before death; and then, after he has been resuscitated, to try to help the patient to solve his problems in other ways. Anyone who wishes to forestall the wellmeant rescue would do well to draw up a solemn declaration of his intention, and formally forbid anyone to interfere with it or lay hands on his person while alive.
I do not know that this has ever been done. But it seems to be lawful, and it might become an accepted practice. If it did, it would solve only a part of the problem. Patients who are very ill and confined to bed are helplessly in the hands of others and have no easy means of suicide. Those who wished to die could perhaps be helped by an amendment to the Suicide Act, releasing from the general prohibition against aiding and abetting a suicide the registered medical practitioner acting bona fide in his professional relationship. A doctor, who would never consider being an 'executioner', might find it easier, if the law allowed, to place the means of death within the reach of his patient, for him to use if he wished of his own accord, neither encouraging nor preventing him.
This would still leave the cases of those who, without realising what has happened to them, lapse into a demented state in which volitional acts are no longer possible. Their predicament would call for a change in the law, to give effect to a declaration made in advance, asking that in such a state they should be allowed to die as soon as possible. This was the substance of a Euthanasia Bill presented in the Lords in 1969 by Lord Raglan, which was defeated, though against a substantial minority.
The present state of affairs in law and in practice is a patent absurdity. In the long run the human desire for comfort will find a way round the distresses and indignities of incurable illness or incapacity. Some me man's need for freedom and self‑determination will win against he forces that keep him in the servitude of a life sentence without emission or parole.