Killing trust between doctors and patients

During my last days, if I am spared a sudden death, I want to be able to look my doctor in the eyes and know that he or she will do the right thing. I want to know that, if I am in pain but fading fast, the doctor will give me enough morphine to alleviate pain and to stop my breathing. Ironically, it is this last act of kindness that is jeopardised if the UK Assisted Dying for the Terminally Ill Bill is ever passed.

Recently, assisted suicide advocates have borrowed some of the hysterical arguments of their opponents in order to further their cause. Opponents of legalisation often talk of a ‘slippery slope’, claiming that doctors, given the green light to assisted suicides, will begin a killing spree and slaughter patients young and old. Rather than challenging that argument with a sober analysis of the facts, proponents of legalisation now use it themselves. They argue that many instances of ‘covert euthanasia’ (note the sinister overtones of this description of what, up until recently, has been an act of kindness) already occur – and say we must therefore legislate to protect the ‘vulnerable’. Inside the breast of all doctors, both sides of the argument agree, beats the heart of a Mengele against whom patients must be protected.

The negative impact of these arguments on the doctor-patient relationship can be glimpsed in the recent treatment of Dr Michael Irwin. Last week Irwin was struck off the medical register by the British General Medical Council (GMC), for trying to help a terminally-ill friend to end his life in 2003. The police had decided not to proceed with a prosecution against Irwin, clearly recognising that it was highly unlikely that any jury in the land would wish to punish him for doing something that doctors have long done in the final moments of a patient’s or friend’s life. But the General Medical Council said Irwin’s actions were ‘irresponsible’ and found him guilty of serious professional misconduct. What message does that send to the next doctor who wants to assist a terminally-ill patient in his or her dying days?

Ironically, Irwin is a campaigner for the ‘right to die’ and a former head of the Voluntary Euthanasia Society. Yet his treatment by the GMC shows precisely the problems caused by the pro-legalisation lobby’s campaign to formalise and legislate for the relationship between doctor and patient in end-of-life decisions.

What would the proposed Assisted Dying for the Terminally Ill Bill change? Are doctors currently embarking on murderous missions, waiting until patients are unable to object? This is one of those questions, like with so many other conspiratorial theories, in which imagination becomes a handy substitute for lack of facts. Certainly, there is no evidence whatever that doctors are snuffing out patients at any greater rate than previously.

Nor is there much support for the worst fears of opponents of assisted suicide. The experience in Holland, Switzerland, Belgium and Oregon (where medically assisted death occurs legally) suggests that the oft-cited ‘slippery slope’ will not happen, despite the fact that the Report of the Select Committee on the Assisted Dying for the Terminally Ill Bill noted that this was the most common objection to the proposed legislation.

Under Oregon’s Death with Dignity Act, which came into force in 1997, physician-assisted suicide has accounted for between 0.06 and 0.14 per cent of total deaths, or somewhere around 40 per year. The estimate for deaths in Britain should the proposed legislation become law is 650. This is fairly insignificant compared with the 4,629 persons that committed suicide in England and Wales in 2003, let alone the total in 2004 of 514,250 deaths. In other words, very few people will avail themselves of this option even if they are given it.

The real effect of the Bill becoming law will be the regrettable formalisation of something that has occurred for many years informally, and mostly unproblematically. No doctor in Britain has so far been successfully prosecuted, much less jailed, for performing this last act of kindness. The ‘double effect’ has been sanctioned in law. Many will recognise the deathbed scene, whereby the doctor, with a meaningful look, announces his intention to make the patient comfortable whereupon relatives and friends exchange glances and nod slowly to give their assent. As Lord Dawson of Penn, admitting in parliament that he hastened the death of King George V in January 1936, said, the action has always been part of good doctoring.

The proposed legislation threatens to turn this act of kindness into a tiresome act of bureaucratic nonsense. First, the patient must make a written and signed request for assisted suicide. The doctor must assess whether the patient’s own assessment that they are suffering ‘unbearably’ is reasonable. The doctor must inform the patient of the prognosis of the disease, the process of assisted suicide, and the alternatives. Clause 3 of the Bill places on the attending physician an obligation to ensure that ‘a specialist in palliative care who shall be a physician has attended the patient to discuss the option of palliative care’.

Once these steps are carried out, they must be repeated by a consultant physician ‘independent of the attending physician’, according to Clause I of the Bill (presumably, this prevents doctors who are Siamese twins from speeding up the process). Then the patient must make a declaration witnessed by two individuals, one of whom must be a lawyer (‘Make way for the lawyer, dear. Move over, father’). The patient must be personally known or show identification (nice to know you get ID’d on the way in and on the way out). Clause 11 makes it an offence to falsify or participate in the falsification of or attempt to destroy a declaration.

Clause 13 and 14 ‘provide for the documentation necessary for an audit trail’ whereby the physician sends the declaration and proof that all the qualifying documents have been met to a commission consisting of a physician, a lay member and – you guessed it – a lawyer. After 14 days – the waiting period required by Clause 1 – the patient may eventuate his or her own death supervised by a doctor.

Leaving aside the question of whether this process furthers ‘dignity’ or, even more ludicrously, ‘autonomy’, as the Bill’s proponents claim, the effect of this legislation would be to destroy the doctor/patient relationship. Never mind the onerous paperwork involved, doctors will be understandably extremely reluctant to take any action with lawyers circling above. Because of the exposition of the entire death-bed scene, all actions taken will be closely scrutinised. As German social theorist Jürgen Habermas’s Legitimation Crisis explained, once a process governed informally is regulated by the state, it throws into question all other informal processes connected with the original process. Regulations beget regulations.

The relentless drive towards making things ‘transparent’ and ‘recognising the needs’ of a small minority of patients opens a veritable Pandora’s box. The concept of the patient as first and foremost an individual will be replaced by a generic ‘patient’ whose even more generic ‘quality of life’ is determined not by individual qualities and relationships but by a flow chart. Instead of dying surrounded by friends and family, we will be surrounded by paper – and lawyers.

Most people, the evidence shows, will want release only from the last hours of life. Most of us will not want assisted suicide or euthanasia until the last minute. Even assisted suicide campaigners like Timothy Leary often back out of the act and die natural deaths. For the sake of perhaps 650 depressed and determined souls per year, the hope for a peaceful death for millions of others are imperiled as a genuine gesture of human decency is ‘made overt’.

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spiked-issue: Euthanasia