23 Nov, 09 | by BMJ
Because 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.