Response to “Murder versus mercy”
Prof Roderick MacLeod
Tuesday, December 1st, 2015
There is so much misinformation and outdated information surrounding the debate about assisted dying that it is important to try to ascertain what evidence is currently available. Otherwise, myths tend to become ‘reality.’
Relief of suffering
The notion that suffering can be relieved is an attractive one but surprisingly there has been little work undertaken to identify exactly what is meant by the word. Of course, individual suffering is just that – individual. Eric Cassell emphasised the importance of knowing the patient and their values (such as opinions, attitudes, and hopes) in order to try and understand what their suffering is.  In Cassell’s view, the nature of the illness and the way a patient responds to it reflects the nature of the patient. It is the striving to understand the intricacies of each individual person that makes palliative care such a rich and rewarding discipline. In a systematic review, Best et al.  revealed that suffering “is multidimensional, oscillating, individual and difficult for individuals to express.” They concluded that “opportunities should be provided for patients to express their suffering. The potential for suffering to be transcended needs to be recognized and facilitated by healthcare staff.” Euthanasia is certainly a short-cut to ending that suffering, but as Best and colleagues suggest, many people do indeed transcend that suffering in their last days or weeks. We should not give up on trying to help them do that. The idea that severe refractory symptoms causing suffering occur in up to 50% of patients is certainly not my experience over 26 years of practice, and indeed the paper quoted is over 20 years old – many advances have been made over two decades.
The ‘slippery slope’
More recent data suggest that the slippery slope is indeed a reality. In the Netherlands in 2013 there has been a 15% increase in reported deaths.  Somewhat alarmingly, there is an increase “in situations of beginning dementia (from 42 people in 2012 to 97 in 2013) and psychiatric diagnoses (from 14 people in 2012 to 42 in 2013).”  The Dutch Review Committees write that “there is an apparent increasing readiness amongst physicians to comply with requests in general and those in case of dementia and psychiatry in particular. It remains difficult to find an unambiguous explanation for this increase in numbers of reported cases.” It is also suggested now that around one in five patients choosing euthanasia in the Netherlands act under pressure from family members. Professor Theo Boer, one of the supporters of the legislation in that country and a member of a euthanasia Regional Review Committee, who has now recognised the dangers of legalising euthanasia, is also especially concerned about the extension of euthanasia as an option for children – a similar situation to Belgium. Perhaps not surprisingly, assisted dying has also increased in Belgium (by 25% over three years), Washington State (by 17% over 3 years) and Oregon (by 30% in four years). These figures are only for reported assisted dying. It is estimated that under-reporting of euthanasia in the Netherlands represents 20-23% of all euthanasia deaths. A more recent example of the loosening of restrictions on premature ending of life is the development in the Netherlands of a network of traveling euthanizing doctors under the name ‘End of Life Clinic.’ These doctors do not need a relationship with the patients they see. Will this perhaps just become another easy way to reduce the ‘burden’ on a family or on society? The British Medical Association has previously stated that “any moral stance founded on the permissibility of active termination of life in some circumstances may lead to a climate of opinion where euthanasia becomes not just permissible but desirable.” 
The involvement of doctors in ending a life will necessarily impact on the doctor/patient relationship. This relationship currently is dependent on mutual trust; however, this bond will become increasingly fragile as doctors seek their boundaries in the issue over life and death changing. Assisted suicide offers no second chances. ‘Terminal’ diagnoses are often wrong or inaccurate in their timing. Perhaps this is why doctors’ groups worldwide are persisting in their opposition of law change. Most recently, the British Geriatric Society (BGS) has published a position paper stating that they “do not accept that legalising physician assisted suicide is in the broader interests of society…older people are often strongly influenced by their families and carers – the vast majority, but not all, will have their wellbeing at heart. Even so, many requests to end life…come from the patients’ families and not the older person themselves.”  As the BGS suggest, “crossing the boundary between acknowledging that death is inevitable and taking active steps to assist the patient to die changes fundamentally the role of the physician, changes the doctor-patient relationship and changes the role of medicine. Once quality of life becomes the yardstick by which the value of human life is judged, the protection offered to the most vulnerable members of society is weakened”.
 Cassell EJ. The nature of suffering and the goals of medicine. N Engl J Med 1982; 306(11):639–645.
 Best M, Aldridge L, Butow P, Olver I, Webster F. Conceptual analysis of suffering in cancer: a systematic review Psycho-Oncology 2015, DOI: 10.1002/pon.3795
 Regional Euthanasia Review Committees Annual Report 2013 [Internet] [cited 2015 July 16]. Available from: https://www.euthanasiecommissie.nl/Images/Annual %20report%202013_tcm52-41743.pdf
 The British Medical Association. What is current BMA policy on assisted dying? [Internet]. 2015 [cited 2015 July 16]. Available from: http://bma.org.uk/practical-support- at-work/ethics/bma-policy-assisted-dying
 British Geriatrics Society. Physician Assisted Suicide [Internet]. 2015 [cited 2015 July 16]. Available from: http://www.bgs.org.uk/index.php/specialinterest-main/ethicslaw-2/4067- position-assisted-suicide