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Independence of a Physician Assisted Suicide Decision Paper

The objective of euthanasia is to allow people who suffer from terminal illness and unending agony to end their life and refusal to permit them to do so would constitute an immoral act. Further, these supporters of euthanasia contend that if an attempt to commit suicide is obstructed then it will result in greater misery to the person who had made such an attempt.

Different people have different views about euthanasia. The belief of religious groups is that life is sacrosanct and a gift of god that can be brought to an end only by an act of god. Some other groups that oppose euthanasia are of the opinion that if euthanasia is enacted or if such killing becomes legal then it may be abused in several ways. Experiences from Holland where voluntary euthanasia has been legalized and where stringent rules have been enforced to prevent misuse of this facility reveal that most of the doctors ignore the statutory formalities. Moreover, it has been noticed that these Dutch Doctors generally fail to realize the importance of contacting the relevant authorities in this context.

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Voluntary euthanasia is a complicated subject that entails ethical arguments. The arguments of the pro–euthanasia activists are that taking one’s life is a matter of personal freedom. In the UK suicide is not construed to be a crime. As such the supporters of euthanasia argue that it constitutes a vital feature of civilisation and that there should be a right to die so that people who suffer from chronic illnesses that involve a lot of pain and suffering can exercise the option to die with dignity and in peace.

It is not an exaggeration to state that the excruciating pain and humiliation that such patients undergo, due to their illness, makes their family members and relatives to consider mercy killing as providing them relief and letting them die in dignity.

This manner of thinking was evidenced in the court trials of Dr Cox who had given a lethal injection to Ms Boyes in order to assist her to end her life voluntarily. The family members of Boyes supported the doctor’s actions. During trial Doctor Nigel Cox accepted that he had given a lethal injection of Potassium Chloride to a fatally ill Ms Boyes, who was of advanced age. She had been suffering unbearable pain and as a result had persistently been pleading with him to end her wretched existence.

Doctor Nigel Cox was convicted of manslaughter and sentenced to prison for a year. This case became more complicated as the patient’s body had been cremated prior to the conduct of an autopsy. The General Medical Council or GMC found that Doctor Nigel Cox was guilty of professional misconduct, but retained his membership even after the conviction. In addition, the General Medical Council directed him to undergo training in palliative care1. The situation obtaining in the United Kingdom is that political leaders, the judiciary and society are unwilling to condone euthanasia in an unambiguous manner.

In another case the doctors of Airedale Hospital in Yorkshire sought permission from the High Court to remove artificial nutrition and hydration from one of their chronically ill patients and this was totally supported by the family members of the patient. The name of the patient was Antony Bland and his left brain had been severely damaged due to an accident. When the Court was approached by the hospital authorities and Bland’s parents to permit them to withdraw the life support systems, the High Court and subsequently the House of Lords permitted the removal of the same2.

Similarly the family members of Mary Ormerod and the hospital authorities obtained permission to remove nutrition and hydration from the Court. This resulted in her death and the family members of Mary were all praise for the care and commitment exhibited by the doctor.

In the UK euthanasia is prohibited and the practice of it has been made illegal. However, lacunae in the legal system permit a doctor to administer an overdose of morphine, even though the doctor is fully aware of the fact that such an overdose can kill the patient. Doctors are immune from prosecution for murder provided they are able to establish that their intention was to alleviate the suffering of the patient. This practice is based on the principle of double effect, which permits doctors to evade responsibility for their deeds.

 It has been contended that doctors generally fail to take sufficient care of the terminally ill patients and that they often fail to employ the latest techniques and drugs for controlling pain. It is a common practice that is undertaken by doctors in hospitals to endorse DNR or Do Not Resuscitate on the case sheets of some patients who are frail. In such situations nurses and doctors will not endeavour to revive these patients on the grounds that doing so may impose an even greater anguish on the patients who in the eyes of the medical professionals are no better than walking corpses.

The general public tends to be more sympathetic towards persons those attempt to kill themselves. The trend observed that the public extends support to efforts for amending the law to withdraw the act that prohibits suicide or to bring about legislation that helps someone to commit suicide. Although majority of the public support the decriminalization of the act of suicide, no political party is taking any positive initiative in this regard. The court’s acquittal of the Northumberland Dr David Moore has created a lasting effect on medical practice in the United Kingdom.

The practice of euthanasia is prohibited in the UK, but the law permits the doctors to provide overdoses of drugs used in relieving pain, if the doctor has no intention to kill the patient by such overdose of painkillers. This is the principle of double effect. This is not a happy situation for doctors as they have to submit to court hearings for their attempts to deliver the best to their patients.

Doctors accept the fact that they had administered dangerous levels of opiate drugs to their patients even though they were aware that such amounts could cause their death. However they never discuss these issues in public for fear of facing prosecution in the court. The usual practise of doctors is to deny these facts if asked to give an official statement. This had been established in the case of Dr Moore who publicly admitted in the media that he had administered overdose of drugs to many of his patients. The outcome of these statements was the commencement of police investigation during which the case of George Liddell was unearthed. In that case George Liddell was an eighty – five year old terminally ill patient suffering from cancer.

Dr Moore was charged with having murdered Liddell. During the trial Dr Moore admitted that though he had administered a very high dose of diamorphine in order to alleviate the suffering of Liddell, his intention had not been to cause death. In an interview Dr Moore further added that he was of the feeling that he was representing the medical profession. The acquittal of Dr Moore had clearly established that the acts of doctors, which intend to relieve pain by the use of drugs is lawful. The legality of such treatment has no bearing on the result of such treatment.

Hence it came to be accepted widely that there is nothing unlawful in administering an over dose of drugs, which can even result in the death of the terminally ill patients, as long as the objective of such treatment was to provide relief from pain. The verdict in the case of Dr Moore provided great relief to doctors. Nevertheless, it is incorrect to conclude that the primary intention of a doctor is to alleviate pain even at the cost of causing the death of the patient.3

Euthanasia is derived from Greek which denotes pleasant death and it construes the killing of individuals in order to put an end to their suffering. The term involuntary euthanasia, assisted suicide or mercy killing has been the subject matter of international debates. The law in the United Kingdom recognizes two types of euthanasia namely active euthanasia and passive euthanasia.

Subsequent to the verdict in the Bland case in the year 1993 physician assisted suicide involving the removal of life sustaining treatment was legally permitted. On the other hand, any act that directly results in the termination of the life of a person is treated as crime in law and is subject to prosecution. Even if the active charge to end life is done with the consent of the dying person it is illegal. Physician assisted suicide where a doctor cooperates with patients to help them to die or if the doctor kills them with a lethal injection, is however accorded legal protection in most of the European countries.

Euthanasia is a complicated subject that raises questions about the government’s actions and the legitimate rights of individuals. Supporters of euthanasia maintain that it is the right of an individual to die in dignity when suffering from a terminal illness. Critics of euthanasia argue that it is the duty of government to see that the fundamental right to life is not violated in any manner. They also argue that if euthanasia is made legal then the government would not be in a position to safeguard the right to life of its citizens.4

Euthanasia is not granted any significant place in the legislation of the United Kingdom. Under certain circumstances euthanasia was considered to be equivalent to murder or manslaughter. The Suicide Act 1961 holds suicide to be legal but it considers involvement in another’s suicide as an offence of criminal liability. There is a vast difference in the prosecution procedures involving euthanasia cases and other criminal cases of murder. The Attorney General has to accord permission to effect a prosecution in the cases of euthanasia according to the act. The sentencing in euthanasia is being affected by the distressing circumstances of the cases. Since 1961 the law was critically examined a number of times but has remained unchanged.

Dianne Pretty was a forty – two year old woman suffering from motor neuron disease. Her physical condition was so terrible that she wanted to commit suicide. Since, her physical condition did not permit her to do so; she wanted her husband to assist her in committing suicide. The Courts held that her husband would be prosecuted if he did so.

An intense and acrimonious battle of words ensued across the nation in respect of the legal and moral issues that this case had raised. Subsequently, he approached the House of Lords but to no avail. He was a much disappointed man when he approached the European Court of Human Rights to initiate a judicial review in respect of the denial of his application and to protect him from prosecution in national courts. The national courts in view of the complicated moral issues involved invoked the sovereignty of parliament. The ECHR also invoked the so called Margin of Appreciation and rejected his plea.5

In effect there are two groups that oppose euthanasia. The first group is the religious group that contends that Christianity does not grant a person the right to die. It believes that life is a gift of god and at the same time it treats suicide as a sin.  The second group debates the rationality of a request for euthanasia, under this principle of rationality it questions the ability of a terminally ill patient to accord consent for his own killing. It also argues that the patient’s relatives and doctors might have used undue influence to bring about consent for euthanasia.

Dr Jack Kevorkian is the leading doctor who is often known as Dr Death. He had committed physician assisted suicide for more than 10 years in the US until he was prosecuted in a case and sentenced to prison for 25 years for having administered a lethal injection.6

Euthanasia signifies in general the humanitarian manner of selecting the time and manner of death of a sick person and specifically the act of extinguishing a person’s life on the basis of the contention that it would be better if that person was.7

When measures are adopted to end a patient’s life then active euthanasia is said to have occurred. If death is brought about by withdrawing the methods of extending life then such euthanasia is termed as passive euthanasia. Voluntary euthanasia takes place when the patient either desires to be killed or is agreeable to being killed. If the patient is killed, despite expressing unwillingness, then such killing is termed as involuntary euthanasia.

Non–voluntary euthanasia transpires if a person, who is considered to be incompetent to decide, is killed by obtaining the consent of a person who is legally empowered to decide on the patient’s behalf. The fact that persons on whom euthanasia is about to be employed are, in general, unable to take important decisions makes it essential to acknowledge the importance of differentiating between involuntary and non–voluntary euthanasia.8

There are very few subscribers, amongst moralists, to the theory that life must be prolonged regardless of the consequences. The tenets of traditional morality preclude directly intended euthanasia as the contention is that it is God who owns the life of a person and that therefore only He can claim it.

The advocates of euthanasia cite the pain and indignity that patients with incurable diseases have to undergo, the problems created by people who cannot lead a normal life and the assumption that people are free to do whatever they like with their lives. One of the non – religious reasons given for prohibiting  euthanasia are that it might be employed with greater frequency and this might make it difficult to determine if death had been the best alternative available.9

If a doctor prescribes drugs that result in the termination of the patient’s life or if nurse gives such medicines to a patient, then both the doctor and the nurse will be deemed to have acted illegally as per the provisions of the Suicide Act 1961. In case the doctor administers a lethal injection to the patient, then legal action can be initiated against him alleging an offense of murder.10

Mens Rea or guilty intent is an important element of the offense of murder. If the victim had been murdered intentionally, then the charge would be one of murder resulting in the punishment of life sentence. In general, euthanasia and assisted suicide cases will be punished with a minimum of prison sentencing.

In instances of mercy killing pleas that have been accepted by the court, a manslaughter plea may be allowed. The Offenses against the Person Act, states that unlawful administering of a poisonous or noxious substance that causes danger to the life of a person is an offense punishable with ten years imprisonment.11

Dr. Arthur had been acquitted by a Leicester Crown Court of the charge of having fatally poisoned a baby that was on the threshold of death. Initially a charge of murder was framed, which was subsequently, reduced to a charge of attempted murder. The Court held that he had not committed an act of positive euthanasia but that he had merely administered a drug that resulted in the peaceful death of that dying child.

A very famous instance of Siamese twins is that of Jodie and Mary. Internal organs like the lungs, heart and brain and limbs like arms and legs were possessed individually by them.  They were joined at the lower abdomen and it was decided by the medical authorities of the UK that they could be successfully operated upon to bring about separation. The only drawback with this course of action was that the weaker twin Mary would have to forfeit her life as she could not live without using the heart and lungs of Jodie.

In fact if Mary had not been born as a Siamese twin she would not have lived as her life would not have been prolonged indefinitely by the use of artificial life support systems.  The cause for her continuing life was a shared artery that enabled Jodie’s heart and lungs to maintain Mary’s life.12

The twins’ parents as pious Roman Catholics considered this misfortune to be an act of God.  However, the doctors attending on these twins were insistent on conducting an operation that would sever the twins and thereby bestow on Jodie a life that was worth living. In order to conduct this operation on the twins the hospital requested the Court’s permission, which was accorded on the 25th of August 2000. The medical classification of this type of conjoined twins is termed as Ischiopagus tetrapus and in such twins there is a fusion at the pelvic level often with a sharing of genitourinary structures, rectum and the liver. The consequence of the surgical intervention was that Mary expired quickly and Jodie survived.13

The   medical   and   legal   ethics   of   conjoined   twins   present an interesting and controversial debate. It is indisputable that parents should be free to take difficult medical decisions in respect of their minor children without any interference from the courts. Nevertheless, if the opportunity exists for saving a child by providing it with medical attention then such treatment should not be denied. The situation can be summed up as confusion worse confounded due to the issues of religion, cost, uncertain outcomes and inherent differences that come into the fray.

It is abhorrent for a parent to have to decide in such a manner that if one child dies the other will survive and if that child is not killed then both the children have to forfeit their lives. Hence, it would be incorrect to gainsay the fact that such pioneering medical operations are fraught with ethical uncertainties.14

A similar surgical operation in Singapore had ended in failure. Two Iranian twin sisters, namely, Ladan Bijani and Laleh were joined at their brain. The hospital authorities spared no effort to ensure that the requirements of ethicality were not violated and in order to provide the best medical aid possible they engaged a group of highly trained doctors in order to successfully countenance any reasonable setback during the surgical procedure. Further, they had made absolutely sure that the concerned parties were in absolutely no doubt regarding the near fatal nature of the surgical procedure. The surgery lasted for quite some time and unfortunately ended in the death of both the twins.15

In the Siamese twins’ case, it became unavoidable to compare the right of each of the twins to life and while doing so it became essential to consider their actual physical condition and the loss or gain of each of the twins from the treatment. This was the crucial factor that accorded Jodie a greater right to life in comparison to Mary.16

It is a fact that the legislation is unable to prevent euthanasia from being practiced by doctors. Although performing euthanasia is still prohibited and illegal throughout the world, a survey conducted in 1992 – 1993 revealed that three hundred twelve general practitioners and hospital consultants had practised euthanasia. Forty – five percent of these doctors had been urged to perform euthanasia and fourteen percent of these doctors had actually carried out euthanasia.17

Health authorities are requested by the doctors to review the health problems of neonates and allow performing active euthanasia in cases involving infants with serious abnormalities and acutely disability. This issue has been thoroughly reviewed and an application has been forwarded by the Royal College of Obstetrics and Gynaecology for according permission to perform euthanasia upon the unhealthiest of infants.

The possibility of active euthanasia has to be analyzed in order to do render help to families. In those cases, if euthanasia were not performed then the families would be subjected to great distress and would have to suffer emotionally and economically for years.  A purposeful action to end the lives of infants would help in decreasing late abortions.

Euthanasia allows mothers to choose their option whether or not to have a disabled child because a highly disabled child would cause distress to the family. Moreover, such a child would cause the family members to undergo mental agony for years and in the final analysis the family would have to put up with a great deal of financial hardship. The Royal College of Obstetrics and Gynaecology opines that the availability of life shortening and purposeful mechanisms would have affected the decision taking of the obstetricians.

The different options that could be exercised by the working party are non–resuscitation, withdrawal of treatment, the best interests test and active euthanasia. These methods widen the management options available in dealing with the sickest of newborn babies.

 Such mercy killings are already being performed in the Netherlands in incurable conditions such as severe spina bifida. John Harris, a member of the official Human Genetics Commission and professor of bioethics at Manchester University, while welcoming the college’s submission stated that it was legal to terminate if there was serious foetal abnormality up to term, but that it was illegal to kill a newborn child. He wondered as to what people thought had occurred in the passage down the birth canal that permitted the killing of the foetus at one end of the birth canal but not the other.

Dr Pieter Sauer, co-author of the Groningen Protocol, which are the guidelines governing infant euthanasia in the Netherlands, said that British medical professionals were already carrying out mercy killings and should be allowed to do so openly.

However, John Wyatt, a consultant neonatologist at University College Hospital, stated that intentional killing was not a part of medical care and that the introduction of the possibility of intentional killing would change the fundamental nature of medicine.

Simone Aspis of the British Council of Disabled People said in this context that euthanasia for disabled newborns tells society that being born disabled is a bad thing. If we introduced euthanasia for certain conditions, it would tell adults with those conditions that they are worth less than other members of society.18

Doctors obtain a special legal status in cases involving euthanasia under which they are exempted from prosecution for their assistance to patients to kill themselves. This legal exemption has always invited controversy. In the US, Oregon State had legislated physician assisted suicide in the year 1997. In the Australian Northern Territory euthanasia was partially legalized in 1996 but that legislation was subsequently revoked. In the Netherlands and Switzerland, euthanasia is practiced although it is not authorized by legislation.

In the UK euthanasia has not been legislated. According to the law, killing people with their consent is murder and helping them to commit suicide is an offence under the Suicide Act 1961. Circumstances where doctors are presumed to have contributed to a suicide by knowingly providing the means, or if they were found to have advised patients about the toxicity of the medication and have intentionally provided information regarding the lethal dosage invite legal action.

Some people contend that there is no practical value in making a distinction between euthanasia and physician assisted suicide. Theoretically the patients have control in cases of physician assisted suicide but in the case of euthanasia the doctor possesses the control. Surveys conducted among several health professionals indicates a belief that there is less moral responsibility or culpability attached to assisting suicide than in performing euthanasia. In a recent UK court case (2002), a judge declared that a mentally alert woman on a permanent life-support regime in a hospital had a right to demand that the support system be switched off.19

Subsequent to the enactment of the Human Rights Act 1998 the supporters of euthanasia have argued that depriving a person of the right to provide relief to a person suffering from excruciating pain becomes humiliating and callous under Article 3 of the ECHR20. Consequently, there is a violation of the right to privacy and family life under Article 8 of the ECHR21, and that this act is tantamount to discrimination regarding the legality of suicide. They also argued that by withholding the right to die, there is a breach of the individual’s dignity under the legislation. Euthanasia is always subject to dispute and is a subject that engenders much discussion. It has resulted in a vast array of debates in the moral, ethical, social, philosophical, legal and religious areas.

The foregoing discussion discloses the fact that physician participation in the active termination of a patient’s life is not free of controversy. There are a number of causes for this situation. The basic and fundamental moral opposition to physician involvement in euthanasia contends that euthanasia infringes the physician’s oath to do no harm.

Nevertheless, several supporters of euthanasia have claimed that a physician violates that oath to do no harm, whenever he prolongs the life of a suffering individual. Moreover, this oath to do no harm is rendered abstruse by the fact that terminally ill patients constitute an extremely vulnerable segment of the population that is almost totally reliant on the medical system. Therefore, it is evident that the physician’s decision to assist suicide or to indulge in mercy killing  does not vary  in accordance with whether the patient is a new born infant, a child or an adult.

References

1.      R v. Cox (1992) 12 BMLR 38.

2.      Airedale N.H.S. Trust v Bland in House of Lords (1993). 2 WLR 316.

3.       Dr Moor: Landmark verdict. November 28, 2000. BBC NEWS. Retrieved on March 11, 2007 from http://news.bbc.co.uk/1/hi/health/background_briefings/euthanasia/331263.stm

4.      Euthanasia. June 29, 2005. Retrieved on March 11, 2007. http://www.politics.co.uk/issuebrief/health/medical–ethics/euthanasia/euthanasia–$366667.htm

5.      Dianne Pretty v. Director of Public Prosecutions and Secretary of State for the Home Department. ( 2002). 35 EHRR 1

6.      Dr Jack Kevorkian, December 1993 Euthanasia. June 29, 2005. Retrieved on March 11, 2007. http://www.politics.co.uk/issuebrief/health/medical–ethics/euthanasia/euthanasia–$366667.htm

7.      The Cambridge Dictionary of Philosophy, © Cambridge University Press 1999.

8.      Ibid.

9.      Ibid.

10.  Section 2. Suicide Act 1961.

11.  Section 23 of the Offenses Against the Person Act 1961.

12.  A (Children), Re [2000] EWCA Civ 254 (22 September 2000)[2001] 2 WLR 480, 9 BHRC 261, [2000] 3 FCR 577, [2000] HRLR 721, [2001] Fam Law 18, (2001) 57 BMLR 1, [2000] 4 All ER 961, [2000] Lloyd’s Rep Med 425, [2001] Fam 147, [2000] EWCA Civ 254, [2001] 1 FLR 1, [2001] UKHRR 1.

13.  Ibid.

14.  Ibid.

15.  Outpouring of grief as twins die. CNN.com/Health. July 8, 2003. Retrieved on March 11, 2007 http://www.cnn.com/2003/HEALTH/07/08/conjoined.twins/

16.  A (Children), Re [2000] EWCA Civ 254 (22 September 2000)[2001] 2 WLR 480, 9 BHRC 261, [2000] 3 FCR 577, [2000] HRLR 721, [2001] Fam Law 18, (2001) 57 BMLR 1, [2000] 4 All ER 961, [2000] Lloyd’s Rep Med 425, [2001] Fam 147, [2000] EWCA Civ 254, [2001] 1 FLR 1, [2001] UKHRR 1.

17.  Pauline Griffiths, PHYSICIAN-ASSISTED SUICIDE AND VOLUNTARY EUTHANASIA: IS IT TIME THE UK LAW CAUGHT UP? Nursing Ethics 1999 6 (2).

18.  Francis Elliott, Allow ‘active euthanasia’ for disabled babies, doctors urge. Whitehall Editor Published: 05 November 2006 Physician-assisted suicide.

19.  Suicide (2006) in Black’s Medical Dictionary, 41st edition. Retrieved March 11, 2007 from http://www.xreferplus.com/entry.jsp?xrefid=5878738;secid=bmd_2001197.

20.  Article 3. European Convention on Human Rights 1950.

21.  Article 8. European Convention on Human Rights 1950.

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