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Tony Delamothe: The Ethics of Assisted Dying – Lord Harries’s lecture

23 Nov, 09 | by BMJ

Tony DelamotheBecause the House of Commons won’t touch end of life issues with a bargepole the House of Lords is the place to watch.

So I went to hear the inaugural Elson Ethics Lecture,  given by Lord Richard  Harries of Pentregarth, on the ethics of assisted dying.(Held at Windsor Castle, we entered via the Henry VIII gate – now there’s a man who made a few end of life decisions in his time.)

As a life peer since he retired as Bishop of Oxford in 2006, Harries has had a ring side seat as the Lords have debated a range of options to loosen the strictures against assisted dying  – none of them going anywhere.

His lecture was short on emphatically stated beliefs and long on description of the issues. By the end, I wondered whether he was still making up his mind on where he stood.

He started by seeking to dispel some misconceptions about the Christian position on several end of life questions. His church accepts the principle of “double effect” – ie it’s legitimate to give patients large doses of morphine to relieve their suffering, even if this hastens their death. (Intentions, not outcome, are apparently crucial here.) And the church has no problems with legally binding advance directives.

Next, Lord Harries gave four reasons why the House of Lords has rejected any change of legislation. Firstly, they were anxious that the old and vulnerable might feel under pressure to request euthanasia if they felt burdensome to others. Secondly, a change in the law might subtly change the relationship between patient and doctor. Thirdly, if assisted dying became legal it might reduce the resources available for palliative care and research. (Harries thought it telling that he has not met a single palliative care doctor who has been in favour of changing the law.) And lastly was the ever present danger of “the slippery slope” – however a law was framed who knew how it might end up?

Later on he denied that it was a cabal of bishops, rabbis, and imams (in Guardian columnist’s Polly Toynbee’s words) who had thwarted any change to the legislation: the opposition was led by palliative care doctors

Moving on to the ethics of the act itself – he believed there were circumstances where it was acceptable to take your own or another’s life. He cited the example of a driver trapped in a burning tanker who asked to be shot. To spare him the agony of being burnt alive Harris thought it was right to accede to his request. But Harries was uncomfortable about legislating for what he saw as these extreme exceptions: “From a Christian point of view, I have hesitations.”

He understood the claims for individual autonomy, he said – after all, the freedom to take responsibility for our lives and decisions is one of the things that makes us human. But autonomy doesn’t trump everything else – we live in a web of mutual dependence: “we are people only through our relationships with others.” Human beings have worth and dignity at all times – it doesn’t depend on our ability to take control of our own lives.

Couldn’t acceding to a request to end someone’s life be construed as compassion? Not necessarily, thought Harries. Acceding to a request is not always the most loving thing to do – think of the suicidal teenager. And from a Christian point of view he thought that there were no situations from which some good could not emerge.

“These four quite specific Christian considerations” made him “very cautious in asking for a change in law for oneself.” But then he said that he really didn’t know how he would behave (were he to become terminally ill.) And perhaps oddly for a man appointed to a legislative body he said nothing about changing the law for those who may not share his specific considerations.

The experience in the US state of Oregon has loomed large in discussions about assisted dying, and Harries then detailed what has happened there over the past decade. In summary, Oregon’s experience provided no support for two of the four objections that swayed the House of Lords. It wasn’t the old and the vulnerable who availed themselves of lethal prescriptions in Oregon: it was largely white, well educated people (average age 72).  It seemed that only a small minority of prescriptions were ever acted on – people wanted the reassurance of a way out, were they ever to need it. The Oregon Hospice Association, initially totally opposed to the new law, had found that demand for hospice places had risen appreciably.

Harries provided the caveats that this was the experience “of just one isolated state” and that it has been “alleged that the system of reporting abuses is not thorough” – without saying who had alleged this and what their evidence was.

Citing the unpredicted outcome of the Abortion Act 1967 (where many more abortions have been performed than were envisaged), he remained seriously concerned about the possibility of the slippery slope. He recognised two forms. The first was the expansion of conditions that qualified for assisted dying (in Belgium apparently anyone over 18 can request it, regardless of underlying condition). And secondly was the drift from voluntary euthanasia (where the patient requests it) to involuntary euthanasia (where doctors and families decide). There had been a “huge debate on what has happened in the Netherlands,” with people arguing that the movement from voluntary to involuntary euthanasia occurred there because voluntary euthanasia was legal.
As for Britain, he wondered whether society would be content to know the factors that the Director of Public Prosecution (DPP) would take into account when faced by a case of assisted suicide. Or would they still want a change in law? Harries looked like he hoped for the former.

After his speech he answered a series of questions from Martin Stanford, presenter at Sky Television. The first was triggered by the DPP’s list of factors for and against prosecution.  Instead of this, “Wouldn’t it be better to have a law that people didn’t have to break?” asked Stanford. Lord Harries was concerned by the message that this would send out to society: “The current law has a positive impact. It says that everybody’s life remains of worth and value.”

He wasn’t impressed that such a high proportion of the public wanted a change in law. Probably a majority are still in favour of capital punishment – but legislators wisely don’t act on this, he said. And does the public really understand what palliative care can offer? Do they know that it’s legitimate for doctors to give them large doses of morphine to relieve their suffering, and that perhaps a third of (?cancer) deaths are hastened in this way?

What did he think of Dignity in Dying’s call for a royal commission on the subject? He thought that  the Health Select Committee of the House of Lords had issued a very good report under Lord James Mackay and that there were  more pressing subjects for royal commissions at the moment – for example, one on London.

Stanford pushed him on his claim that no situation was devoid of hope. Harries then reflected on the plight of his mother, who had suffered a stroke that blighted the last years of her life. He thought some good had come from it – in terms of how her family had co-operated over her care.  He quoted Edwin Muir’s: “Strange blessings never in Paradise Fall from these beclouded skies.”

But Stanford didn’t follow up with the tough question for the lecturer who was so comfortable with the principle of double effect. If the intention of assisted suicide had been to reduce his mother’s suffering, wouldn’t its benefits to her far outweigh the benefits experienced by her family? And while Harries asked who could not fail to be moved by the plight of the quadriplegic rugby player, he didn’t say what he thought was preferable to his parents taking him to Switzerland to die.  He thoroughly disapproved of Dignitas, but didn’t say what’s better.

Does Lord Harries have a position on the prohibition of assisted dying? Twice he said words to the effect of “But I don’t know how I’d respond if I were in that situation.”  To people who are in “that situation” – like Debbie Purdy – or people who can manage the necessary imaginative leap, Lord  Harries didn’t have a great deal to say.

Tony Delamothe is a deputy editor of the BMJ.

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  • Pingback: Comment: BMJ blog misinformation about end of life decision-making in Belgium, the Netherlands and the UK « KCL Medical Ethics and Law

  • David Evans

    What did you expect from an Anglican bishop Tony?

  • http://www.bmj.com/ Peter Lapsley

    The assisted dying debate

    Tony Delamothe’s account of Lord Harries’s lecture on the ethics of assisted dying raises a number of interesting issues.

    Not least amongst them is the question as to how, in an increasingly multi-faith and secular society, there can be some 26 Church of England Bishops sitting in the House of Lords, especially as every one of them is, almost by definition, amongst the most practised and persuasive speakers in the House. In her paper, ‘Religion, law and medicine: Legislating on birth and death in a Christian state’ (http://medlaw.oxfordjournals.org/cgi/pdf_extract/17/3/410), Elizabeth Wicks, Senior Lecturer at the Birmingham Law School and the Institute of Medical Law at Birmingham University, offers a thoughtful and coherent analysis of the controversial role of religion, specifically Christianity, in legislating on such matters as assisted dying. In particular, she shows how religious representation can be an invidious restraint upon ethical decision-making. Perhaps this is a matter that could and should be addressed in the government’s apparently stalled efforts to reform the House of Lords.

    Then there is the question of the involvement of palliative care clinicians in the assisted dying debate. Lord Harries is reported as having “thought it telling that he has not met a single palliative care doctor who has been in favour of changing the law”. There may be a reason for that. Back in February, my own blog about the assisted dying debate (http://blogs.bmj.com/bmj/2009/02/03/peter-lapsley-on-the-assisted-dying-debate/#more-577) elicited a response from, Dr Ian Johnson, a retired palliative care physician, in which he said that he, “…had a duty to uphold the reputation of the hospice where I worked. It would have been inappropriate to become known as the doctor who believes in euthanasia, a reputation which would undoubtedly have damaged public confidence in the hospice.”

    It is interesting, also, that it is always the same palliative care physicians who speak up for their profession with promises of a “good death” when, in reality, palliative care provision across the UK is underfunded, patchy and variable in quality. (I am not sure that Lord Harries would have stated so categorically that “human beings have…dignity at all times” had he witnessed my father’s death over eight years, which involved between six and eight strokes, the eventual amputation of a leg and then three months of utter misery, severe phantom pain and dreadful loss of dignity. In his case, and despite kind and committed nursing home staff, effective palliative care was most noticeable by its absence.)

    It was disappointing to learn that Lord Harries had tritely trotted out the “the slippery slope” argument as one of the reasons for the House of Lords’ rejection of any change in the legislation. If true, it shows both a lack of awareness by the Lords of what the public want and a disconcerting lack of confidence in Parliament’s ability to provide it. Successive polls have shown overwhelming public support for a law allowing medically assisted dying for the terminally ill, and a significant number of doctors prepared to provide such assistance.

    Finally, it was surprising, too, to see that Lord Harries had fallen into the old trap of comparing the public’s attitudes to assisted dying with their views on capital punishment. There is no comparison. The former is an option a few individuals may choose for themselves and for which they must bear responsibility; the latter depends on a judgement taken by the State in respect of someone else, and one the State may get wrong.

    Peter Lapsley
    Patient editor, BMJ

  • http://dignityindying.blogspot.com/ James Harris

    I think that you hit the nail on the head.

    Palliative care, as acknowledged by those who practice it, cannot alleviate all of the suffering the dying process can cause. If we do not provide terminally ill, mentally competent adults, who consider their suffering unbearable, with the choice of an assisted death, are we as a society content for them to suffer?

    The great difficulty with this issue is that there needs to be a debate about what a law should look like (for example what safeguards are needed to protect against abuse) but such debate is often stifled by those with an immutable objection to assisted dying (regardless of the safeguards proposed). Proponents of a change in the law like myself must acknowledge that there are genuine concerns about the impact on potentially vulnerable people, but opponents should acknowledge that if they can’t add to this debate rationally, they should not impose their views on others who do not share them. To do so is to create unfounded fears of a ‘duty to die’, whilst imposing a real and present duty to suffer.”

    James Harris
    Head of Campaigns and Communications
    Dignity in Dying

  • Richard Smith

    I’d always thought that palliative cares were all against assisted dying, but I’ve now met at least one who sees assisted dying as entirely compatible with the values of palliative care of helping people die as well as well as possible and being patient led. Indeed, if they are the values of palliative care (and surely they must be)then how could palliative care physicians be against assisted dying in all circumstances?

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