Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Suffering not rights justifies ending lives
- Peter J Allmark (8 April 2005)
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But it doesn't feel like it
- Neville W Goodman (8 April 2005)
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freedom of choice
- steven,e willow (8 April 2005)
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'Intention' means there is a world of difference
- Andrew N Fergusson (8 April 2005)
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Right not to die
- John D Holden (8 April 2005)
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Grayling's "Right to Die" terrifies me
- Alison Davis (8 April 2005)
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Life and Death
- Christopher O'Loughlin (8 April 2005)
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Bad legislative interpretations of the “right to life” and the “right to death” could threaten the basic philosophy of palliative care.
- John C Chambers (9 April 2005)
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No “right to die” and no “right to be killed”
- David I Jeffrey (9 April 2005)
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"Right to life" must not be used to impose death upon the defenceless.
- Adrian Joseph Treloar (9 April 2005)
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Objection from the philosophical point of view
- Pablo Requena (9 April 2005)
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Changing 'right' to die to 'duty' to die.
- Joe Brierley (10 April 2005)
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Right to life: Is it different in developing countries
- Vijayashankara. Nanjegowda (10 April 2005)
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Re: Grayling's "Right to Die" terrifies me
- Herman A. Borkent (10 April 2005)
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Courts have already decided right to life doesn't imply a right to die
- Christopher S A Wayte (10 April 2005)
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The Right To Die
- Lesley A M Evans (11 April 2005)
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Right to life and Right to die versus Gift of life and Inevitability of death
- Dr Marie B. Mc Devitt (11 April 2005)
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Right to die? Right to live!
- S G Barber (11 April 2005)
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Is the Right to life dependant on a minimum quality?
- Michael R Jarmulowicz (11 April 2005)
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Good quality of life: death is the antithesis
- Claire A Stark Toller (12 April 2005)
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Ultimate solution
- Sujith K Dhanasiri (12 April 2005)
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Re: Is the Right to life dependant on a minimum quality?
- Joan McClusky (12 April 2005)
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Life is not always a good?
- Luis Ayerbe, Maria Perez-Pinar (12 April 2005)
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Relief of suffering
- Vladimir Lazarevik (12 April 2005)
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Flawed arguments in "Right to Die" editorial
- Peter KK Au-Yeung (12 April 2005)
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Re: But it doesn't feel like it
- Ruth M Linney (13 April 2005)
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Re: Is the Right to life dependant on a minimum quality?
- Joan McClusky (13 April 2005)
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End-of-life decisions in the context of limited resources
- William O Tarnow-Mordi (14 April 2005)
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Fear and Loathing
- Mark Struthers (14 April 2005)
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The Right to Die
- Peter J Watkins (14 April 2005)
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Right to die is unethical and absurd
- Anil Pandit (14 April 2005)
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A better way to die than this
- Mark Houghton (14 April 2005)
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The ethics of withholding treatment
- Richard M Lindley (15 April 2005)
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Problems with "Right to Die" Editorial
- Victoria J. Wheatley, Simon I.R. Noble (15 April 2005)
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No man (or woman) is an island
- Andrew G Rivett (15 April 2005)
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Assisted death, personal autonomy and human rights
- John C Chambers (15 April 2005)
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Re: The ethics of withholding treatment
- Peter KK Au-Yeung (15 April 2005)
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Count me out
- Gregory C Brown (15 April 2005)
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Re: Re: The ethics of withholding treatment
- Stewart SW Chan (16 April 2005)
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Playing God.
- Anil Pandit (18 April 2005)
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After death?
- julian kennedy (19 April 2005)
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cannot quantify quality of life
- Vasantha Kumar (21 April 2005)
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A misleading editorial
- Gregory Gardner (22 April 2005)
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it was permanent vegetative state
- Jim Howe (27 April 2005)
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Re: Assisted death, personal autonomy and human rights
- Andrew N Papanikitas (6 May 2005)
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Not the last word.
- Gregory Gardner (23 May 2005)
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Peter J Allmark, Senior Lecturer School of Nursing, Sheffield University, SFH, Northern General Hospital, Sheffield S5 7AU
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Grayling argues, first, that the right to life entails a right to die because “life” means more than “bare existence”. As such, someone who barely exists should be allowed to die or even killed. This seems a tortured argument. Its conclusion amounts to saying that killing someone who “barely exists” is respecting his right to life. The right to life is a right not to be killed if it is anything at all. If it is occasionally correct to let someone die, or even kill him, then this is to do with ending suffering: that is all. Grayling goes on to criticise the distinction between withholding treatment and actively killing someone. He argues that if the result will be death in either case then there is no moral distinction between them. This is sometimes true: if I intend to end someone’s life it makes no moral difference whether I do so through starving him or through lethal injection. However, most legal statutes do not recognise, say, the withdrawal of assisted nutrition from a comatose patient as an act that is undertaken with the intention to kill. Rather it is viewed as an act in which one withdraws a treatment that is not doing the patient any good. This is what happened in Schiavo’s case. Many clinicians find this distinction far from “fictitious”. Competing interests: None declared |
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Neville W Goodman, Consultant Anaesthetist Southmead Hospital, Bristol, BS10 5NB
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With these words: "Lawyers and doctors distinguish between withholding treatment with death as the result, and giving treatment that causes death. The first is considered to be permissible in law and ethics, the second is not. But in fact there is no difference between them; for withholding treatment is an act, based on a decision, just as giving treatment is an act, based on a decision." Professor Grayling illustrates the difference between the philosopher or ethicist and the clinician. In fact, as a clinician, I can tell him that, when faced with someone you judge is going to die anyway, there is a world of difference between withholding nutrition and water and giving a lethal injection. Whether it would be better to give the injection is another matter, but it will never feel the same. Competing interests: None declared |
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steven,e willow, retired 17841,home
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each person alive should have the choice of liveing or dieing.no one but god himself has the right to tell anyone how to live or die.it should be the persons choice of wanting to live or die.the great leaders of our nation has no right to tell anyone if they should live or die but like everything else they put ther power into action and try to run our lives and so far they cant even run ther own country right so what or who gives them the power to run anyones life or death.thank you very much steven.from the united states. Competing interests: right to live or die |
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Andrew N Fergusson, Strategy Advisor, Christian Medical Fellowship Christian Medical Fellowship, 157 Waterloo Road, London SE1 8XN
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About the only redeeming feature of Grayling's unhelpful article is that at least the title is in inverted commas: "Right to Die" is of course a meaningless expression. All of us are going to die and doctors rightly struggle to treat disease and injury and prevent unnatural deaths. What is of course being advocated in this empty slogan is an alleged right to be killed by a doctor, which is something very different. Regarding 'withholding treatment with death as the result, and giving treatment that causes death' Grayling claims that 'in fact there is no difference between them'. Nonsense, and nonsense that will be recognised as such by every medical reader of this philosopher's muddled article. Grayling completely ignores the deeply held, widely understood and essential concept of intention - the issue of 'what did the doctor mean to do when (s)he performed this act?' There is a world of difference between stopping a treatment that doctors are under no duty to provide because it is ineffective or because its burden outweighs its benefit (and I am not thereby agreeing with the decision in the case of the late Terri Schiavo), and performing an act with the intention of killing a patient. We have recognised this since the time of Hippocrates ('I will give no deadly poison to anyone even if asked') and it is an eternal truth reflected in ethical principle and in the law of the land. Why does a leading article in the BMJ on the philosophical and ethical aspects of end-of-life treatment not even mention the concept? If Grayling understood it, it would have prevented him writing his subsequent unhelpful inaccuracies about the 'doctrine of double effect'. Please can these vital issues be discussed comprehensively from the context of the real world? Competing interests: Currently working as Strategy Advisor on Euthanasia to the Christian Medical Fellowship |
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John D Holden, General practitioner Garswood Surgery, St.Helens WN4 8LD
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Since Professor Grayling discusses assisted dying without reference to those who are frightened, frail, lonely or elderly and usually consider themselves 'a burden',are we to assume he has never met such people? Competing interests: None declared |
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Alison Davis, Patient Home DT11 0LE
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Grayling argues that there is a "right to die" for some sorts of people - those who have lives that do not measure up to his "minimum quality" and those who cannot express their views, but are thought by others to be "better off dead." In doing so, he suggests that the "right to life" entails also a "right to die." This was not the view taken by the House of Lords in the case of Dianne Pretty. It was said then by Lord Justice Tuckey that "In our view the right to human dignity which is enshrined in Article Three [of the Human Rights Act] is not the right to die with dignity, but the right to life with as much dignity as can possibly be afforded until that life reaches its natural end." This is necessarily so, because the right to life is an inalienable right - a right of which one may not be deprived, and of which one may not even deprive onself. I note that Grayling supports the "right to die" for people who "maturely judge their quality of life is below the minimum" set by him. I once made that judgement about my life. I have spina bifida, hydrocephalus, emphysema and osteoporosis. I use a wheelchair full time. I also have very severe spinal pain which is not fully controlled even with morphine. Twenty years ago, when doctors thought I was terminally ill, I decided I wanted to die. It was a settled wish that lasted 10 years, and during the first five of those years I made several serious attempts to end my life. I was treated against my will in hospital, by doctors who recognised and respected my right to life when I could not recognise or respect it myself. I owe my life to their actions. Had euthanasia or assisted suicide been available then I would have requested "help to die." Under Grayling's rules (and those which apply in Holland, where euthanasia is legal) I would have qualified for this. I would have been killed, and thus deprived of what have been the best years of my life. It would have seemed, 20 years ago, that my situation was hopeless. I was in extreme pain, apparently terminally ill, and had a determined and settled wish to die. Had I been killed, no one would ever have known that the future held something better for me. Now I still have the same degree of spinal pain, and increasing levels of disability. What has changed is my outlook on life. The "right to die" allows no changes of mind, no mistakes, no chance to be helped to regain a sense of the value of one's own life. I find Grayling's promotion of this supposed "right" for people in my position truly terrifying. Competing interests: None declared |
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Christopher O'Loughlin, Psychiatry SpR OPMHS, Fulbourn Hospital, Cambridge CB1 5EF
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Sir, The dangers of AC Graylings argument on the right to die cannot be underestimated (1). By re-defining phrases, conflating ideas and confusing what is legal with what is good, Grayling seeks to persuade that a right to life is a right to be killed. The right to life as, for example, laid out in the Universal Declaration of Human Rights in 1948 (2) has no implications that this has a "quite rich" quality including a right to relationships and being free from distress and pain - nor that a life lacking these qualities is therefore valueless. The de-criminalisation of suicide and rights of patients to refuse life saving treatment are due to the principle of autonomy rather than a subjective right to die, and do not imply that the decisions the individual makes are therefore good. There is no equivalence of witholding treatment and giving treatment in either ethics or law. In law because the Actus reus of a crime must, under normal circumstances, be a positive act and not an ommission. In ethics, because a judgement of treatment futility bears no relation to a supposed judgement of below-threshold quality of life; the former being a judgment of the treatment and the ultimate inevitably of death, the latter of the patient. Would Grayling really say that there is a moral equivalence between witholding antibiotics in a patient dying of cancer and, to use a graphic example, taking a revolver and shooting the patient ? Perhaps such an outcome is of no suprise if Grayling believes that ethical decisions are made in a vacuum of dispassionate logic and that ideas of politics and religion are simply "sentiments" that obscure. Yours, Dr. C O'Loughlin (1) Grayling AC. "Right to Die", BMJ, 2005;330:799 (2) General Assembly of the United Nations, "Universal Declaration of Human Rights", Resolution 217 A (III),10 December 1948 Competing interests: None declared |
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John C Chambers, Macmillan Consultant and Medical Director Katharine House Hospice, East End, Adderbury, Oxon, OX17 3NL
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Editor- I could not agree with Grayling that there is no difference between withholding treatment with death as a result, and giving treatment that causes death (1). I was also surprised by his claim that a “right to life” means a right to a minimum quality of life that is quite rich. The right to life, as described in Article Two of the EC Convention for the Protection of Human Rights and Fundamental Freedoms, says nothing whatsoever about quality of life (2). Rather, it says that no one shall be deprived of his life intentionally, save in the execution of a sentence of a court following his conviction of a crime for which this penalty is provided by law. It then describes three exceptional situations where citizens or law enforcement agencies might kill a person without apparently being in infringement of the victim’s right to life. Perhaps the right to life is actually a “right not to be killed”, which makes more sense as all mortals ultimately die, and “death on request” for the many people on the planet who live in poverty with a quality of life less that that described by Grayling strikes me as the wrong solution to the problem. Changing the focus from a “right to life” to a “right not to be killed” could be very helpful to medicine where, non-paradoxically, “right to life” is generally considered in relation to ensuring survival rather than legitimizing assisted death. However, for reasons that are hard to understand, it appears that right to life has been interpreted as a patient’s right to cardiopulmonary resuscitation regardless of the clinical circumstances (3, 4). This same interpretation could logically lead to a right to dialysis, ventilation and organ transplantation, to name but a few, in the belief that such treatments preserve life and their denial causes death in certain circumstances. By applying the right to life in this way to medical matters, our culture actually appears to prioritise patient choice, and possibly length of life, over the quality of life considerations described by Grayling, but the result is not necessarily any more desirable. This apparent prioritization runs the risk of unpalatable and potentially unsustainable consequences for health services and, in the case of cardiopulmonary resuscitation in the terminally ill, it is hard to know which would be the greater burden on one’s conscience: simulated or half-hearted resuscitation attempts that were never intended to succeed or proper resuscitation attempts where the chances of success are vanishingly small and the likelihood of major fractures and other injury is very high. With regard to the right to die, I agree with Grayling that patients have rights to freedom of thought, privacy and the refusal of treatment. This means that they can wish for their life to be terminated without being obliged to explain why. It also means that health professionals risk being charged with battery if they inflict treatments or care upon patients for which consent was not given, with the exclusion of treatments administered under the Mental Health Act. Patients also have a right to attempt suicide, but to a right to assisted dying equates to a right to be killed and therefore a right that somebody else must kill or help to kill them on their request. It has been suggested that this is a role for doctors, with involvement of palliative care specialists along the way (5). For this to become a reality, at least some doctors must be given the right to kill when requested to do so, which is a very different scenario indeed from withholding treatment or the double effect. The withholding of treatment relates to interventions that are unable to produce the desired benefit (6), which is generally meaningful improvement in the health or sense of wellbeing of the patient. In palliative care, it is unlikely that withholding such treatments causes death, which is probably better viewed as the natural consequence of an irreversible and unsustainable pathological burden. Secondly, rather than death being the ultimate analgesic, I suggest that death without adequate analgesia might be the ultimate pain, not just for the patient who experiences an undignified closure to their life but for the bereaved friends and relatives whose final memory is of terminal distress and the health professionals who are left with a sense of failure to establish peace when it was most needed. Judicious use of analgesics and other medication is therefore an essential part of good terminal care and, in fifteen years as a doctor, I am yet to see a death that I can attribute due to analgesic overdose. Therefore, I believe Grayling’s innuendo that the double effect is widely used or abused is itself fictitious. Palliative care affirms life until the moment of death, and regards death from advanced incurable disease as a natural process (7). Its interventions are intended to relieve pain and other distressing symptoms, thereby enhancing remaining quality of life whilst neither hastening nor postponing the moment of death. I suggest that this encapsulates the human “death rights” from advanced incurable disease that should be protected by legislation. However, the very future of palliative care could be jeopardized by ill-conceived legislative changes that take the right to life or the right to death beyond sensible limits or give certain doctors the right to kill on request. 1. Grayling AG. “Right to die” The moral basis of the right to die is the right to good quality life. BMJ 2005;330:799 2. Council of Europe Convention for the Protection of Human Rights and Fundamental Freedoms as amended by Protocol No. 11. http://www.echr.coe.int/Convention/webConvenENG.pdf (Accessed 08/04/05) 3. HSC 2000/028: Resuscitation policy. http://www.dh.gov.uk/PublicationsAndStatistics/LettersAndCirculars/HealthServiceCirculars /HealthServiceCircularsArticle/fs/en?CONTENT_ID=4004244&chk=1DaKY/ (Accessed 08/04/05) 4. Higginson IJ. For and Against. Doctors should not discuss resuscitation with terminally ill patients: Against. BMJ 2003;327:615-616 5. Assisted dying for the terminally ill bill. http://www.parliament.uk/parliamentary_committees/lordsassisted.cfm (Accessed 08/04/05) 6. British Medical Association. Withholding and withdrawing life- prolonging treatment: guidance for decision making. London: BMJ Books, 1999. 7. World Health Organisation definition of palliative care. http://www.who.int/cancer/palliative/en/ (Accessed 08/04/05) Competing interests: None declared |
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David I Jeffrey, Chair Ethics Committee of the Association for Palliative Medicine of Great Britain & Ireland Ellem Lodge, Duns ,Berwickshire TD 11 3SG
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Dear Editor, Grayling suggests that a right to life means a “right to die” and a right to be killed. (1) The fact that suicide was decriminalised in the Suicide Act of 1961 was not because the law condoned suicide but rather a pragmatic response to the impracticality of prosecution; assisting suicide remains a serious offence. Almost all societies have a strong prohibition against unjust killing : no legal “right to die” exists. The proposal that such a right should exist is illogical as it would impose a duty on society to kill on request; a “right to be killed”. In claiming that there is no moral distinction between killing by an act or by an omission, Grayling ignores the morally relevant distinction between foreseeing and intending a death(2) Yours sincerely Dr David Jeffrey
1Grayling AC “Right to die” BMJ 2005;330:799 2Keown J Medical murder by omission? The law and ethics of withholding and withdrawing treatment and tube feeding Clin Med JRCPL 2003;3:460-3 Competing interests: None declared |
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Adrian Joseph Treloar, Consultant Memorial Hospital London SE18 3RZ
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Professor Grayling attempts to suggest that a right to life implies a right to die. He then states that the death of Terri Schiavo was the outcome of a "right to die". In fact she died as a result of legal action by others which denied her right to life. He goes on to suggest that religious sentiments may obscure decision making. I would argue that defending the right to life is a humanitarian issue. If, as Professor grayling suggests, defending life is a religious activity, the defenceless will be grateful for religion. Perhaps that explains the enormous love and respect shown to Pope John Paul II following his death last weekend. Competing interests: None declared |
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Pablo Requena, Assistant Professor P. U. Holy Cross
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In the response of Allmark and Goodman is well presented, from the clinical point of view, the real distinction that many times exists between "withholding treatment with death as the result, and giving treatment that causes death". But also from the ethical point of view this distinction exists. Here there is not space to consider the wide debate regarding "letting die" and "killing". However, it is easly to grasp that we can withhold some kind of treatment (with death as the result) without intention of killing, but we cannot give a treatment to cause the death of the patient without the intention of killing. We can have two very different actions even if the external configuration is the same: the same administration of a strong sedative could be done with intention of relieving a pain, or wiht the intention of killing the patient. This is why sometimes "withholding treatment with death as the result is not the same as giving treatment that causes death". Competing interests: General bioethics |
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Joe Brierley, Consultant Intensivist Great Ormond Street Hospital. LONDON WC1N 3JH
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The predictable outcry over Grayling's editorial (1) has added little to an emotive debate. The concept of a right to die is clearly in accordance with the current obsession with autonomy in vogue in UK medical ethics. Responses re-stating Christian objections to any perceived undermining of the right to life and objections from physicians about the lack of moral difference between ommission and commision being secondary to effects on the moral agent are not fundamental to the issue. Both, incidentally views I share. A more rigorous ethical refutation is, I feel, found in moral argument against our rights based culture. In a sense replacement of the term 'right' by the term 'duty' focuses the debate. Once the initial reactionary problems are explored as in Hardwig's article we can, in accordance with our inter-dependant human society, enable each and every one of us to prepare for the best death we can achieve with the appropriate palliative care support. 1. Grayling AG. “Right to die” The moral basis of the right to die is the right to good quality life. BMJ 2005;330:799 2. Hardwig J. Is there a duty to die? Hastings Center Report 27, no. 2 (1997): 34-42. (http://web.utk.edu/~jhardwig/dutydie.htm) Competing interests: None declared |
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Vijayashankara. Nanjegowda, Professor of Pediatrics SDUMC, Kolar, India. 567103
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Dear Editor, The editorial by Dr.Grayling and the various responses to it made a very interesting and enlightening reading. I was following miss Terry Schiavo's case closely and I do agree with the decision taken by the court. But what happens in developing countries is a different one. The laws are same and some what more rigid in these countries. But the medical decision to end life is influenced more by the financial considerations than by the sanctity of life. Miss Terry Schiavo would not have lived for the long 15 years, if she had been born in a devloping country and had been in a vegetative state. The governments in these countries do not have the means to take care of similar patients, neither the husbands, the parents and the relatives. so the arguments over right to live and right to die are meaningless.In the developing countries the right to life is not ensured at all by the governament for the people who do not have the minimum means for a living, let alone for a decent living.The right to die arguments becomes superfluous here. The whole relevance of the ethical considerations itself are different here. Competing interests: None declared |
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Herman A. Borkent, Clinical Associate Misericordia Hospital Edmonton T5R 4H5
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I agree with Alison Davis' position on "the right to die". Most of my medical career has been in a hospital Emergency Department. Several times a week I have had to treat young, healthy patients who have taken an intentional overdose of medication. They all felt their quality of life to be intolerably bad at that time. Provincial laws in Alberta require that we resuscitate these patients, properly recognizing that society does not allow 'death on demand'. Competing interests: None declared |
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Christopher S A Wayte, GP No 18 surgery, Upper Oldfield Park, Bath BA
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Professor Grayling's editorial on 9th April makes the assertion that a right to life entails a right to die also. He also states that decisions on this issue are best undertaken in a court of law. It is significant that the European Court of Human Rights considered this issue in the Diane Pretty case, and concluded that the right to life did not imply a right to die. If one accepts Professor Grayling's suggestion that the law court is the right place to make decisions on this issue, his assertion that there is such a thing as a right to die has already been ruled as incorrect by the European Court of Human rights. yours sincerely Chris Wayte Competing interests: None declared |
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Lesley A M Evans, Retired Consultant Geriatrician Previously at Musgrove Park Hospital, Taunton, Somerset
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Sir, I read with considerable interest the leader by Professor A C Grayling. I was Medical Officer to a small Hospice in the early days of the Hospice movement, and I was for 12 years a Consultant Geriatrician with a special interest in palliative care. My many years' experience of caring for the dying have led me to believe that sometimes it is wrong to encourage or assist people to hang on to life until the last moment - there are worse things than death. I agree wholeheartedly with Professor Grayling's assertion that people have the right to decide when and how they die. Their lives and their bodies belong to them, not to the medical staff or even to their relatives. Too often medical and nursing staff have tended to take over patients' bodies, as though they owned them and knew what was right for them. We must learn to be less arrogant and less controlling as a profession, and allow patients more autonomy. This is happening in general hopitals more, as patients become better informed, but the Hospices still tend to be rather too proprietorial about their patients. We need the utmost sensitivity and humility when dealing with the dying. It is too easy to be patronising and assume we know what's best. We are not in their shoes. I agree too that there really is no difference at all between witholding treatment, with death as the result, and giving treatment that causes death. We are kidding ourselves if we think there is. I believe we must grasp this nettle, for our patients' sakes, and offer a compassionate and peaceful death to those for whom palliation is no longer relieving their distress. We fail in our duty to them otherwise. Yours sincerely, Lesley Evans Competing interests: None declared |
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Dr Marie B. Mc Devitt, Public Health Specialist Stockport PCT, Regent House, Stockport SK4 1BS, England
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Prof Grayling argues we have a 'Right to die' because we have a 'Right to life'. However, even though it may be not be conventional I prefer to view these as a 'Gift of life' and an 'Inevitability of death'. In this day and age, particularly in the developed world, no one should suffer unnecessarily with the administration of tender, loving care (TLC) and adequate pain relief. There is a fine line to be drawn between giving pain relief to relieve suffering and giving it deliberately to hasten death. What could it do to the consciences of doctors if they cross that line? What effect could it have on doctors' morale and ethical behaviour? Other commentators have written that in 1930's Nazi Germany euthanasia was introduced for vulnerable and devalued groups which then preceeded the genocide of the Jewish people. For those of us who believe in God, should not some discretion be allowed God for the timing of our death as well as our birth. Competing interests: None declared |
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S G Barber, consultant West Cumberland Hospital, Cumbria CA38 8JG
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11th April 2005. Editor – Grayling’s “Right to die” editorial (9th April) raises more problems than it solves. The decriminalisation of attempted suicide does NOT make it morally or ethically acceptable, which are separate arguments. Who says that individuals wanting (their own) death can do so “maturely” – and what does his wish to imply by using the emotive term? Most of the world’s major religions find suicide unacceptable. Surely this is not accidental? “Considerations of humanity…implying … the supplementary right to painless … dying” does not necessarily include killing them! It is not only “lawyers and doctors” who differentiate between withholding treatment where death might ensue and giving treatment that directly causes death. Grayling chooses to ignore generations of philosophers and theologians, to mention but a few others! His choice to deny the principle of double effect should have been explicitly stated as being ‘in his view’. This principle is still widely held – not least by 1.086 BILLION Roman Catholics worldwide! Sadly, this was a woolly editorial, with surprising leaps of sentiment. Readers of the BMJ deserve better! Competing interests: None declared |
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Michael R Jarmulowicz, Consultant Histopathologist Northwick Park Hospital, HA1 3UJ
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Professor Grayling states:- “For life in the phrase ‘the right to life’ does not mean bare existence; it means existence that has a certain minimum quality for its possessors....” I am sure the reason this statement is not referenced, is that no such legal qualification exists. If it did, then that minimum quality would need to be legally defined. The reality is that Professor Grayling is employing verbal engineering as a prelude to the social engineering he wishes to bring about. It is of interest that many are now promoting personal autonomy as the great driving principle of modern ethics, whilst forgetting that this word is derived from two roots ‘auto’ (self) and ‘nomos’ (law) which in essence means being a law unto oneself; the principle which underpins anarchy. The only reason for defining rights, which have to be based on universal truths, is that it requires the state to uphold those rights. It is nonsensical to argue that a right is granted by a state, otherwise it would be equally possible for that state to withdraw that right and the notion of ‘rights’ would have no meaning. If the right to life had a qualification of minimal quality, then the state would be entirely justified in saying that it would not fund care for those falling below the quality standard. Do we really want to practice medicine in such an environment? Competing interests: None declared |
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Claire A Stark Toller, SpR Palliative Care Oxford Deanery, HP21 8AL
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Editor-it is difficult to see how a right to life could possibly entail that which is its antithesis: death. There are no quality qualifications intrinsic to the right to life and it is not clear how Grayling can justify their introduction. Similarly, the pursuit of autonomy cannot impose upon others the obligation to provide assistance in any matter including death. As a trainee in Palliative Care, my understanding of the implications of "considerations of humanity" is that I should not judge my patients' lives as below some arbitrary minimum quality, and then kill them, even at their request, but rather to cherish them and enable them to live the best life possible until natural death. Competing interests: None declared |
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Sujith K Dhanasiri, Health Policy Student London WC2A 2AE
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If Prof Grayling's suggestion of "right to die" is implemented, it could then be interpreted as a medically legal solution to a health problem. No questions asked about the doctors competency to treat an illness or access issues to appropriate care - why should they ? Isn't delivering a painless death the ultimate solution to all bodily ills! And then governments could institute performance indicators for more efficiency ! Competing interests: None declared |
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Joan McClusky, Medical writer New York, NY
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For many people, ie, those in the concentration camps of WWII, mere existance as in the absence of death was good enough. It strikes me that it is only those societies with previously unheard -of standards of medical care, housing, food, and education that are suddenly deciding life has an intrinsic value only when certain standards are reached. In fact, the idea of life being of intrinsic value has been around for millenia--even as most people died before the age of 40, were slaves, starved, died in childbirth, or a host of other features of everyday life that are totally alien to modern developed countries. Competing interests: None declared |
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Luis Ayerbe, GP Grimsby, Maria Perez-Pinar
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I cannot say that I agree with the statement "Mere existence can not be considered a good". In my opinion the life, even the most deteriorated one, has always a value. It is valuable for you and for people around you (No one is an island). Moreover I think that this value is there although the person whose life it is may not see it. But society should consider it. When working with severely handicapped people, it is easy to see how valuable they are despite their unability to work, to produce any profit, to tell intelligent histories, even to talk, to walk or to move properly. Materialistic points of view do not consider many fields of the human being which are not too practical but certainly are a wealth. Competing interests: None declared |
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Vladimir Lazarevik, Lecturer Department of Social Medicine, Medical Faculty Skopje
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The tragic story of Mrs. Terry Schiavo caused eruption of controversial commentaries in the world media and it included many medical, ethical, legal, humanistic, and familiar dimensions. The case opened many difficult questions which would always result in opposite opinions. What to do when the patient can not decide on his/her life? Whether to let the patient to die with dignity of to be life supported for years? Who is to make such decision? Who will cover the expenses of such treatment? How many other human lives could be saved with the funds allocated to maintain such life? Ethics in health is based on the basic concepts and values of a society. If the concept of sanctity of human life is above all other societal considerations, than all available measures should be used to safe the human life. However, if the struggle to safe one human life is struggle to prolong the suffering, than it is morally justified to act preventively and to interfere with divine will, when the ethic obligation is limited on intervention to relief the suffering. Humanism balances these two ethical imperatives: saving of a life and relief of suffering. Maybe Terri Schiavo was relieved of suffering that has lasted for 15 years. The decision for many is tragic and equal to murderer, but for many is justified and even delayed. These stressful life stories forced us to think deeper and beyond the reality of everyday living, but the truth for the justice of the moves and decisions we make would remain elusive and endless, forever. Competing interests: None declared |
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Peter KK Au-Yeung, Specialist Anaesthetist Hong Kong
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Prof. Grayling’s editorial on the “Right to Die” fails to persuade that the “right to die” is somehow based on a right to life. The assertion that life “does not mean bare existence; it means existence that has a certain minimum quality for its possessors, where the minimum is quite rich,…” is made without any supporting reasons and assumes that everyone is in agreement with this view. There is clear dissent from this, as witnessed by many of the rapid responses already published. Furthermore, it could easily be argued that the idea, that the life in “right to life” means existence with a certain minimum (quite rich, as Grayling then asserted) quality, provides a justification for denying the right to life of those whose existence fails to meet these minimum qualities - qualities not properly defined in the editorial but nevertheless open to arbitrary definition. In other word, it can be twisted to provide justification for disability discrimination and eugenics. The arguments relating right to die to respect for personal autonomy also present problems. Personal autonomy is never unlimited, no matter which jurisdiction one happens to be in. The Hart-Devlin debate often mentioned in relation to theories of jurisprudence illustrates this amply by putting forward differing views on the limits which should be imposed by law to personal freedom. Even the most liberal of jurisdictions allow personal free rein only to the extent that it does not interfere with the autonomy or freedoms of others. However society often still draws a line short of that and not every act between two freely consenting adults remain immune from society’s disapproval or sanctions. The case of the German cannibal Armin Meiwes who obtained his victim’s consent before killing and then eating him is a case in point. The statement that “Death, after all, is the ultimate analgesic.” is highly controversial as it appeared to equate death with therapy. A dead patient has no further need for symptom or pathology control, because either would be utterly irrelevant. Reductio ad absurdum, does the professor really want doctors to admit that killing the patient is better than caring for them or trying to cure their diseases? Debates in medical ethics gain from philosophy input as it provides a different perspective from which doctors rarely view the world. Let us welcome more philosophy input into medical ethics debates with the intellectual rigour we have come to expect from that discipline, so that we may be informed and hope to be elevated from mere doctors into real thinkers. Competing interests: None declared |
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Ruth M Linney, PRHO Warwick Hospital, CV34 5BW
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I couldn't agree more. Having trained for 6 years to do a job I love and care about, including a bachelors degree in Ethics, I have great difficulty reconciling myself to the idea of purposefully terminating a life - no matter what the quality of that life is. There are ways to improve quality of life without ending that life. Every doctor knows what it is like to treat a patient and for them to die despite your best efforts - it is difficult and worrying. I cannot imagine how I would feel if it was in my job description to purposefully carry out a procedure I know would end a patients life, even if they wanted it. The doctrine of double effect is an entirely different concept - it allows for us as healthcare professionals to treat a patient with dignity, respect and care, and to manage their symptoms effectively. In addition, 'quality of life' is not only a subjective concept, but one which is fluctuant and changeable. Can vulnerable people in pain and despair fairly be asked to make a competent decision whether to end their own lives? The Suicide Act recognised this by decriminalising suicide - in effect no longer considering it a rational and purposeful act but a response to psychological stressors. We already have plenty of provision to care effectively for patients who are in pain, distress and the terminal stages of their illnesses. This includes withdrawing treatment for patients when we do not consider it to be in their best interests. Problematic cases make it to the national and international media, and cause much debate, but they are resolved, and usually with the outcome everyone can recognise as the most appropriate. Is there really any need to ask doctors to kill people deliberately? Competing interests: None declared |
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Joan McClusky, Medical Writer New York, NY
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When Dylan Thomas's father was in his 80's, he was blind and frail. He wrote "Do Not Go Gentle into that Good Night" to encourage his father to fight against death. He starts: Do not go gentle into that good night,
And finishes: And you, my father, there on the sad height,
Competing interests: None declared |
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William O Tarnow-Mordi, professor of neonatal medicine University of Sydney, Westmead Hospital and The Children's Hospital at Westmead, NSW 2145, Australia
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Professor Grayling wrote that “It is perhaps characteristic of humankind that it regards reasoned choices about when and how to die as morally problematic, whereas ignoring the question and hoping for the best is seen as acceptable or even right.” Professor Nanjegowda Vijayashankara reminded us of the need to consider such decisions in the context of limited resources. This is particularly salient for those who care for the small minority of babies who are receiving mechanical ventilation for inevitably lethal conditions in neonatal intensive care units (NICUs). A prospective study in 54 UK NICUs showed that occupancy was linearly related to the odds of risk-adjusted mortality. (1) In other words, the more babies already receiving intensive care in a NICU, the more likely it was that a newly admitted baby would die. This is likely to reflect the effects of increased staff workload. If we ignore the question of limiting intensive care when it cannot prevent, but only prolong, dying, one consequence is that preventable deaths may be more likely to occur. William Tarnow-Mordi 1 Tucker J; for the UK Neonatal Staffing Study Group. Patient volume, staffing, and workload in relation to risk-adjusted outcomes in a random stratified sample of UK neonatal intensive care units: a prospective evaluation. Lancet. 2002;359:99-107. Competing interests: None declared |
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Mark Struthers, GP Bedfordshire, UK
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At the moment I enjoy a certain ‘joie de vivre’. There is a certain minimum quality to my life: I don’t want to die. Tomorrow I may feel differently and may wish to exert my ‘right to die’. No one else can have a say in whether I live or die – not my friends or relatives or any of my dearest loved ones. They have no say because they are not me. I have autonomy. I decide what I do. Whether I live or die is my choice. It doesn’t need to be enshrined in law; it is a fact of life. I can stick a gun to my head and blow my brains out like Hunter S Thompson did - if I want to. My friends and family would be devastated of course, but it would be a death of my own choosing at a time and place that suited me. If I am not in a position to choose my end then I am left with rules. A ‘living will’ could have ensured a trigger man to do the deed and finish me off. Without such direction as in the case of Terri Schiavo “the dispassionate assessment of the facts in a court of law is the best way to reach a conclusion”. However, I fear the meddling Republican politician. I loathe the right wing religionist. I hate their dichotomy in thinking: both proclaim pro-life credentials and yet neither have a problem with the anti-abortion and pro-death penalty aspects of life in American society. It is a blessing that Florida ultimately ignored these unhelpful types. The law and some kind of wisdom finally prevailed in Terri Schiavo’s case. That is a good. At least that gives some hope for a future in what looks set to be the American century. Email: mark.struthers@which.net Competing interests: None declared |
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Peter J Watkins, Honorary Consultant Physician Royal College of Physicians, London NW1 4LE
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I hesitate to disagree with Professor Grayling(1), but I cannot accept that there is no difference between withholding treatment and giving treatment that causes death. Advice to withhold treatment is normally given in situations where patients are already dying of their disease. There is therefore a profound difference between this and giving treatment which directly kills the patient. The crucial issue is to make a 'diagnosis of dying'(2), and then manage the process of dying to alleviate suffering, rather than make it worse by administering futile treatments. Withholding treatment then is not, as Professor Grayling suggests, the cause of death. Peter Watkins
1 Grayling AC. Right to die. BMJ 2005;330:799 (9 April). 2 Higgs R. The diagnosis of dying. J R Coll Physicians Lond 1999;33:110-12. Competing interests: None declared |
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Anil Pandit, Research Fellow Patan Hosital, GPO 252, Kathmandu, Nepal
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Let us imagine a hypothetical world where people have to right to die as a fundamental human rights and doctors assisting the painless and comfortable death. The world's situation would be exactly opposite that of today. We would have many patients waiting outside in the clinic for painless and comfortable death. People would be discussing amongst themselves about who is the best doctor who can provide them best death instead of best life. It would further imply that, if people try to commit suicide, they should be given the freedom to do so. If patients of attempted suicide come to ER, ER doctors would quietly sit down and either watch or help that person die! In cases like Terri Schiavo's who are doctors, court or any other third parties to decide what is the best quality of life for her? If we are taking decision on her behalf aren't we taking her rights of autonomy. The fact that she was in vegetative state means that she had equal chances of having free will to die or live. In case like hers, the most practical and relevant move would have been to take nation wide referendum and see what would be the opinion of majority of normal human beings. Competing interests: None declared |
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Mark Houghton, Freelance GP Sheffield, S. 10 4EF
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Professor Grayling's philosophy for intentionally hastening death (9 Apr 2005, page 799) is empty of enduring core values. While this may be typical of parts of Western society it is not the duty of doctors to support it. Far better is to be encouraged by the award-winning letter in BMJ News Review this week illustrating the immense benefit from doctors caring diligently throughout a last illness.
Furthermore he is inaccurate. Humankind has not been “ignoring the question and hoping for the best of how and when to die”. Untold millions have faced death with conviction as their anchor. Vast numbers have died in faith like the late Pope. They have died at peace in the knowledge that the time of their dying was in God’s good hands. Yes, we will all be granted our "right to die" at some point. But the right to kill is not ours, whatever a philosophy might say. Competing interests: I have been suicidal from pain in the past. |
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Richard M Lindley, Research Fellow Institute of Child Health, Liverpool, L12 2AP
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I am in the minority of those responding to this article, but I must agree with Professor Grayling in his assertion that deliberately withholding treatment with the intention to kill is morally equivalent to deliberately acting in another way to cause death. I was interested in the attempt by Dr Goodman and others to construct an emotionally based ethical system in which the validity of an action is determined by the "feeling" of the practitioner, but must object to a theory that would condone rape if the rapist was comfortable with the action. This is not a reasonable way to object to Prof. Grayling. I would therefore like a better explanation from those that believe he is wrong. Specifically, I would like to see an analysis of the following case: withdrawal of fluids/feeding from a patient diagnosed with PVS (who will inevitably die as a consequence of their withdrawal) versus giving the same patient a fatal dose of (for instance) morphine. Is it wrong to administer the morphine but acceptable to stop fluids? If so, why? Both choices involve an act of commission - removing a tube/stopping a drip or injecting a drug. Both have the same effect. One cannot argue that the intention is different either, as a doctor stopping fluids/feeding in such cases knows what the consequence of their actions will be. We are therefore left with the only possible ethical difference between the two actions devolving to some notion of the effects upon society when such actions are performed. Given that the personal ethical implications are identical (as outlined above), this would imply that "society" is treated either as ethically inferior (unable to make such fine distinctions) or as having a different set of moral standards. I do not (yet) want to broaden the scope of this discussion to whether it is correct to withdraw feeding in a PVS patient - merely to explore the difference between the two acts (withdrawing feeding and giving a lethal injection). Competing interests: None declared |
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Victoria J. Wheatley, SpR. Palliative Medicine, All Wales Higher Training Scheme Velindre Hospital, Whitchurch, Cardiff, CF14 2TL, Simon I.R. Noble
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It is difficult to know where to start in commenting on Professor Grayling’s article (1): it is so shot through with misconceptions and prompts so many questions. Professor Grayling believes that the ‘right to life’ which appears in human rights laws includes “a certain minimum quality for its possessors, where the minimum is quite rich, giving its possessors access to a range of basic human goods such as relationships and in which they are as free as reasonably possible from distress and pain”. These are certainly laudable ideals, but ideals are not rights, notwithstanding the tendency in some quarters to label as a right anything which is regarded as desirable. But Professor Grayling goes further, alleging that ‘personal autonomy’ is another human right and that, under this banner, the so- called right to die is just like other (alleged) rights, such as choosing “whom to love” and “whether to have a family”. Professor Graying goes on to suggest that these putative rights include “a supplementary right to assistance of the kind medical science can provide in dying painlessly and easily, since this concerns the quality of the lived experience of dying”. Medical science is there to cure (where it can) and to continue to provide care (when it can’t). But to ensure “the quality of the lived experience of dying” is another matter entirely. There are many dimensions involved in the achievement of this ‘quality’ – spiritual, social and intellectual as well as medical – which is precisely what coordinated palliative care strives to bring about. We are continually improving our ability to deal with physical symptoms, but medicine cannot deal with the pain which results from loss of personal control and an unwillingness to accept the limitations which terminal illness imposes on lifestyles, which (as the House of Lords report (2) makes clear) are what lie behind the really serious requests for euthanasia. The problem with what is called euphemistically ‘assisted dying’ is not the dying but the assisting: it means making the medical profession undertake ‘therapeutic killing’. Professor Grayling believes that the distinction between the double- effect doctrine and euthanasia is ‘fictitious’. As she is a philosopher, she can perhaps be forgiven for misunderstanding the double-effect principle. It occurs in almost every branch of clinical activity, but very rarely related to analgesic prescribing. To claim that “death, after all, is the ultimate analgesic” suggests that Professor Grayling regards death as no more than a form of oblivion. Perhaps she does: there are others who take that view. But the point at issue here is that death is to most people a special – to many the most special – event in life, whether from a religious or a secular standpoint, and not just a means of avoiding mental or physical suffering. That is why society, notwithstanding its increasingly secular character and notwithstanding the decriminalisation of suicide, goes to great lengths to prevent suicide. This is not a case of human nature acting unreasonably. There are some fundamental human values at play, the existence of which Professor Grayling fails to recognise. Victoria J. Wheatley SpR. Palliative Medicine, All Wales Higher Training Scheme Simon I.R. Noble SpR. Palliative Medicine, All Wales Higher Training Scheme Velindre Hospital, Cardiff, CF14 2TL 1 Grayling A.C. “Right to die” BMJ 2005; 330: 799 2 Assisted Dying for the Terminally Ill Bill [HL] – First Report http://www.publications.parliament.uk/pa/ld200405/ldselect/ldasdy/86/8602.htm (accessed 14 Apr. 2005) Competing interests: None declared |
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Andrew G Rivett, SCMO in Health Protection Hampshire & Isle of Wight Health Protection Unit
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Editor - John Donne would have had no intention, had he been writing today, of establishing a male norm when he wrote, "No man is an island, entire of itself; every man is a piece of the continent, a part of the main." Professor Grayling points out with great clarity how the right to life implicitly includes within itself a right to a certain basic quality of life, and therefore a right to die if that quality is impossible. My ethics teacher reminded me that where there is a right, there is also a duty. Where there is a right to die, there is also a duty to live, and die, not just as an individual, but as a part of a web of all humanity, of all life, one can even argue as a part of all being in the universe. My life, and my death, are not absolutely my own to do with just as I choose. I have a responsibility to live my life, and to die my death, to the best that I can in the light of this web of all being which I personalise as God. There is a marked danger in the on-going discussion on euthanasia and physician-assisted suicide that we regard ourselves and our family and friends and patients as no more than individuals. Our rights must be exercised in the light of our duties. As Donne says, "Any man's death diminishes me, because I am involved in all mankind." Andrew Rivett Competing interests: None declared |
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John C Chambers, Macmillan Consultant and Medical Director Katharine House Hospice, East End, Adderbury, Oxon, OX17 3NL
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Editor - Having read the Grayling’s editorial “Right to die” (1) and “The Underlying Ethical Principles” contained in the House of Lords’ Report on the proposed Assisted Dying for the Terminally Ill Bill (2), I considered it important to familiarise myself better with the concepts of human rights and personal autonomy. Whilst I am no philosopher or legal expert, it struck me as perfectly obvious that absence of legislation permitting assisted death was not an infringement of one’s human rights. On the other hand, I could see no way in which an Assisted Dying Bill could be shown not to breach the Universal Declaration of Human Rights (UDHR) and the Council of Europe’s Convention for the Protection of Human Rights and Fundamental Freedoms (CPHRFF) without the use of weasel words (3, 4). It has been argued by the House of Lords that the division of opinion over assisted dying boils down to differences in balancing the right to personal autonomy against the sanctity of life, and Grayling’s editorial appeared to be a curious defence of personal autonomy. A human right is any basic right or freedom to which all humans are entitled by virtue of being human. Adopted by the United Nations 56 years ago, the UDHR describes the inalienable rights of all humans, including the right to life, liberty and security of person. The Council of Europe's CPHRFF reaffirmed the profound belief of all its members in the UDHR. With regard to life, it said: “Everyone's right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which this penalty is provided by law”. Autonomy is the state of self-government rather than government by a larger social grouping of which one is a part. In organised society, personal autonomy is subject to limitations, many of which are defined by law. Indeed, fear that unrestrained personal autonomy for all would lead to a state of inequality, danger, fear and chaos is an important argument for ensuring that we all remain governed and that we generally agree to it. The UDHR makes clear that individuals have duties to the democratic societies in which they live, just as these societies can only limit individual freedoms by law when this is necessary to ensure the recognition and respect of the rights and freedoms of others or to meet the just requirements of morality, public order and general welfare in that society. As it is a legitimate role of law to limit personal autonomy, a petition for greater personal autonomy has no extra dimensions to it than a simple request for laws to be changed, so long as the laws in question do not infringe universal human rights. However, this simple request has been presented as the strongest case for assisted suicide. Another acceptable definition of autonomy is freedom from the intervention of others. Naturally, some interventions are welcome whereas others are unwelcome, but an unwelcome intervention need not be a breach of one's right to privacy if, for example, it respects the rights or freedoms of others or protects the morality of society. Bearing these two definitions in mind, it appears that autonomous acts fall into two categories. Firstly, there are self-governed and completely self-executed autonomous acts. Suicide falls into this category and legislation regarding this is found in the 1961 Suicide Act. Secondly, there are autonomous acts that are self-governed but require some degree of outside assistance for their successful execution. If these acts are truly autonomous then they are clearly limited by the extent of one’s right to assistance. Assisted death falls into this category. Therefore, in the debate over assisted death, it could be argued that the differences of opinion over the right to personal autonomy are more accurately differences of opinion over the right to assistance. What exactly are an individual’s rights to assistance? The closest that the UDHR gets to such a statement is Article 25: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control”. The CPHRFF contains no equivalent clause. However, considering the general ethos of both documents, it would seem utterly implausible that assisted death would count as an acceptable form of security in the event of sickness or disability and rather likely that it would be an infringement of Article 30 of the UDHR which reads: “Nothing in this Declaration may be interpreted as implying for any State, group or person any right to engage in any activity or to perform any act aimed at the destruction of any of the rights and freedoms set forth herein.” Suppose these considerations could be dealt with in a manner that allowed assisted death, what legislative changes would be required? Firstly, individuals would have to be granted the right to demand that someone be found to end or help to end their life on request. This would appear to go further than simple freedom of thought or expression. Secondly, at least some people would have to be granted the right to be involved in actively terminating the life of another person under strictly defined conditions. This completely contravenes Article Two of the CPHRFF at the very least. Now let us suppose that certain individuals are actually granted the right to assisted death. The group that is currently proposed comprises competent adults with advanced incurable illness who are in unbearable distress and have a probable prognosis of two months or less. As the case for assisted death is founded upon the principle of personal autonomy, how can it possibly be argued logically that this right only exists for some competent adults and not all? Surely the population as a whole will include many non-terminally ill individuals with equal levels of distress that is believed to have little or no prospect of ever abating. There is no reason why some of these should have no serious medical complaint whatsoever. Furthermore, might not the distress of a child sometimes be just as great as that of an adult? Why are these people being denied the supposed autonomy of assisted death? But wait, there appears to be yet another inequity between those eligible for assisted death and those who are not. Presumably assisted death will involve a procedure that ends life quickly, painlessly and with certainty and this will take place in an environment with company, a feeling of dignity for the dying person and complete immunity from resuscitation attempts. How many suicides are like this? Aren’t they often lingering, painful, ineffective, lonely and undignified affairs, and aren’t resuscitation attempts generally made when attempted suicides are found? Such inequities might not be accepted for long. People often talk about the slippery slope of euthanasia, where it is feared that the legal safeguards start to slip with the result that doctors start euthanasing people who neither requested nor qualified for it. Might there be a second type of slippery slope, one where society becomes so comfortable with the idea of assisted dying, it is demanded as a general right for all rather than the exclusive right of a very few? It would appear that Lord Joffe, proposer of the Assisted Dying Bill has visions for expansion in the future. When questioned by the House of Lords Committee, he said: “We are starting off, this is a first stage… I believe that this Bill initially should be limited, although I would prefer it to be of much wider application, but it is a new field and I think we should be cautious... When we considered the opposition to the previous bill, we felt that there was such strength of feeling in the debate about extending it to younger people who had a long lifetime ahead of them that we thought it wise… to limit it to terminally ill patients who were already suffering terribly and had a very short time to live. But I can assure you that I would prefer that the law did apply to patients who were younger and who were not terminally ill but who were suffering unbearably, and if there is a move to insert that into the Bill I would certainly support it” The House of Lords has recommended that the next step should be for assisted dying to be debated early in the next session of parliament. The Bill proposed by Joffe gives the responsibility for assisting in deaths to doctors. If this is a development that interests you, then after the General Election in early May is the time to make your opinion known to your local MP if you want to have a part in shaping this historic democratic decision. References 1. Grayling AC. Right to die. BMJ 2005; 330:799. 2. Part One of the House of Lords Committee Report on the Assisted Dying Bill. http://www.parliament.uk/parliamentary_committees/lordsassisted.cfm (Accessed: 13/04/05) 3. United Nations Universal Declaration of Human Rights. http://www.un.org/Overview/rights.html (Accessed 13/04/05) 4. Council of Europe Convention for the Protection of Human Rights and Fundamental Freedoms. http://www.echr.coe.int/Eng/BasicTexts.htm (Accessed 13/04/05) Competing interests: None declared |
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Peter KK Au-Yeung, Specialist Anaesthetist Hong Kong
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I agree that there is absolutely no distinction between withholding or withdrawing or even limiting a treatment with the express intention of killing and effecting that killing via a more direct method, such as a lethal injection. In my mind, given that the express reason for the removal of Terri Schiavo's feeding tube is to terminate her life, there is actually no moral difference between stopping her feeding and shooting her in the head. Withholding , withdrawing and limiting therapies in the intensive care unit can often be quite different. When the blood pressure of a critically ill patient does not stop falling despite increasing doses of inotropes, it certainly suggests that the therapy is ineffective. Limiting or even stopping it poses no moral problem - after all it could even be the wrong therapy for that patient and sometimes no deterioration results with the withdrawal. Similarly withholding renal replacement therapy is perfectly acceptable if by its institution, the treatment produces a disastrous worsening of cardiovascular parameters. Alternatively, if the renal failure is just the latest in a catalogue of organ systems failures, most of which are not amenable to treatment, and which when added together is not compatible with survival, withholding haemofiltration is just acknowledging that medical technology is not going to win the day and any lengthening of survival is just delaying the inevitable. What if therapy had already been started when the above picture emerges? The ethics should be the same and withdrawal would be ethically equivalent to withholding the same therapy in the same circumstances. Much as I would disagree with Prof Grayling's editorial, I support the argument that withdrawing therapy with an intention to kill is morally equivalent to say giving a lethal injection. Contrary to Grayling's assertion, intention is important and the principle of double effect is relevant. After all this reply is all about the principle of double effect. Competing interests: None declared |
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Gregory C Brown, Final year medical student Sheffield, S6 4AB
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I am disturbed by the insidious way in which this agenda is being advanced. The patient's 'right to die' equates to giving doctors the right to kill, and the real casualty is the bond of trust between doctors and patients. The profession must take a stand before the nature of our practice is irrevocably altered and our patients can no longer be certain of our intentions. Hippocrates understood the importance of upholding the sanctity of human life, and the following from anthropologist Margaret Mead is worth quoting at length: "For the first time in our tradition there was a complete separation between killing and curing. Throughout the primitive world, the doctor and the sorcerer tended to be the same person. He with power to kill had power to cure, including specially the undoing of his own killing activities. ... With the Greeks, the distinction was made clear. One profession, the followers of Asclepius, were to be dedicated completely to life under all circumstances, regardless of rank, age, or intellect - the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child. . . . [T]his is a priceless possession which we cannot afford to tarnish, but society always is attempting to make the physician into a killer - to kill the defective child at birth, to leave the sleeping pills beside the bed of the cancer patient. . . . [I]t is the duty of society to protect the physician from such requests" - Mead M. quoted in Marker R et al. Euthanasia: a historical overview. Maryland J Contemporary Legal Issues. 1991;2:257-298. Competing interests: None declared |
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Stewart SW Chan, Emergency Physician Prince of Wales Hospital, Hong Kong
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I agree with Dr. Au-Yeung and I also support the argument that withdrawing therapy with an intention to kill is morally equivalent to say giving a lethal injection. The problem is easier if the patient is irreversibly deteriorating and dying, and supportive therapy is futile to prolong his life. However, the situation becomes difficult otherwise. To simplify the opinions already expressed by other respondents on the article, I would like to pose a series of questions for pondering: Would society allow: 1. A mentally deranged lunatic committing suicide? 2. A mentally retarded or incapacitated person committing suicide? 3. A terminally-ill patient in much suffering committing suicide? 4. A vegetative patient, who is not brain-dead and can maintain all her vital signs independently, committing suicide? Where do we draw the line? Competing interests: None declared |
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Anil Pandit, Research Fellow Patan Hospital, GPO 252, Kathmandu, Nepal
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I agree with Grayling in his arguments about withholding treatment with death as the result and giving treatment that causes death. Both are acts made on a decision with an intention to kill. Ethics and law if they allow such acts need to be amended. The act of withholding treatment gives enormous power to the doctors to kill. How can they decide to terminate a life if they have no power to give? In the condition where the chances of recovery are much less, the best way is to let nature take its course. Hastening the natural process by withholding treatment, food, water and other basic life supports seems very unethical, and raw. This is playing God !! Competing interests: None declared |
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julian kennedy, staff grade Plymouth -Derriford Hospital
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Mr Grayling states that he believes 'Death ,after all, is the ultimate analgesic.'I have to disagree.If he was inferring that all after death feel nothing then he is mistaken. If the Bible is true and Jesus can be trusted then death is not the end of existence-there is an eternity of painless joy and bliss in God's presence in heaven but conversely an eternity of pain and torment in hell. See Luke 16 vers 23.As regards the right to die-this is God's prerogative and any assisted suicide is self murder and is a sin. Competing interests: None declared |
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Vasantha Kumar, locum Consultant (Endocrinology) QMC Nottingham NG7 2UH
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I raise the same question as Dr.Holden ("Right not to die"); Many contributors on this topic, including Prof.Grayling appear not to have had much experience among the very group of people whose futures are likely to be affected by this type of discussion. 'Quality of life' is not something that can be reliably and reproducibly assessed; what is a good bank balance these days?! Does the 'certain minimum quality' of life that Prof.Grayling suggests vary between the young and the old? the rich and the poor? the literate and illiterate? those who can fend for themselves and those who cannot? I would argue that only the person concerned can decide whether his or her life is worth living but even then we know that most decisions to end life are incorrect. And because unfortunately conflicts of interest cannot be ruled out fully, any decision should err in favour of maintaining life whenever opinions have to be obtained from family members or others where the patient is incapable of communication. Even those who say, "I would never want to become dependent", would or may want to live on when the unthinkable has happened; but, powerless by then, they may well succumb to their own 'living will'. The Will lives but the owner dies! Another disturbing feature in the discussion is the fact that feeding and hydration are being touted as 'treatment'. The suffering that must be caused by denying these elements is played down or completely neglected, simply because the patient is unable to argue! We know starvation will kill sooner or later; most medical 'treatments' are not curative, and not effective in everyone. Denying such treatment cannot be equated with denying basic needs of an organism- why not switch off the heating and lighting, stop all cleaning and get rid of clothing and shelter? Killing Terri Schiavo by starvation and dehydration was inhumane murder. If it was in her interest to die, and the sages of the world seemed to have agreed on this, murder by lethal injection would have been much more in her interest! Competing interests: physician |
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Gregory Gardner, Associate General Practitioner Cape Hill Medical Centre, Raglan Rd., Smethwick B66 3NR
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The case of Terri Schiavo which prompted the editorial by AC Grayling has been misreported. Terri was not on ‘life support’ or ‘a life support machine’ as Professor Grayling[1]and the BMJ[2],[3] alleged. She was receiving her nutrition via a feeding tube. At one point in the days prior to her death, a group of disability activists turned up at the hospice in their wheelchairs and displayed their feeding tubes. Their point was simply that they were also dependent on a basic piece of plastic tubing but that this was a long way from being on life support. Not only the BMJ but also the media in general have misreported the case. Misleading references were made to Terri being comatose, or in a persistent vegetative state[3] (to use that demeaning term). Video footage[4] showed Terri smiling in response to her mother and able to respond to music and other stimulation. Under Florida law, Terri’s guardian (her husband Michael Schiavo) was supposed to have had a plan for her rehabilitation. The only plan presented was to arrange her death through the courts. Professor Grayling is correct in saying that someone who starved another person to death would be as liable for murder as if he or she had poisoned the person. This is exactly what happened with Terri Schiavo. During her 13 day enforced starvation and dehydration a police officer was present in the room to ensure that she was not allowed even to have any ice to assuage her thirst[5]. The murder of Terri Schiavo marks another turning point in medical ethics. Not just the case itself but the indifferent reaction to it shows just how cheaply we value human life. This was not a case where a treatment was thought to be futile (she was not terminally ill), but where the patient themselves was found to be burdensome. Terri’s life was considered to be an encumbrance. Professor Grayling thinks that ‘a dispassionate assessment of the facts in a court of law’ has ‘quite properly happened in Terri Schiavo’s case.’ He is wrong. 1 Grayling AC. Right to die. BMJ 2005;330:799 2 Charatan F. President Bush and Congress intervene in ‘right to die’ case. BMJ 2005;330:687. 3 Charatan F. U.S. Supreme Court refuses to intervene in ‘right to die’ case. BMJ 2005;330:746 4 http://www.terrisfight.org 5 http://priestsforlife.org/euthanasia/terrisfinalhours.htm Competing interests: None declared |
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Jim Howe, neurologist Airedale NHS Trust BD20 6TD
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This week the New Engl J Med contains a clear review of the Schiavo case. Expert neurologists were agreed many years ago that she was in PVS. A few seconds of video on TV is not a comprehensive neurological assessment Dr Gardner, and the US courts deliberated carefully on the evidence and reached a conclusion which her poor parents could not accept. The sadness is that they were able to use the court process to prolong her existence, make her dying a public spectacle and allow the religious right in Congress to try to interfere with the courts. As Judge Renquist said in the Cruzan case referring to a PVS patient being alive: 'this is not life as ordinary people understand it'.[1]
[1] Cruzan v. Director, Missouri Dept. of Health, 110 S. Ct. 2841 (1990). Competing interests: None declared |
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Andrew N Papanikitas, SHO in Paediatrics Eastbourne DGH, BN21 2UD
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Has anyone ever been successfully prosecuted for preventing a suicide, or for interfering, perhaps in so much as calling the emergency services? This might imply that the 1961 suicide act equates to a right to die. Has anyone successfully sued a hospital trust for treating an overdose or other attempt at self destruction? (PS though no obvious cases spring to mind these are not rhetorical questions -I would like to know the answer!) Consider living wills and advance directives. Opposing lobbies fantasically appear to agree that these exist with the intention that 'passive euthansia' be permitted for those no longer unable to voice a competent refusal of treatment, having once had that ability. Is the idea of preventing unwanted treatment then a delusion? In not providing the life-saving blood transfusion to the card-carrying (a form of advance directive)Jehovah's witness are we practising passive euthansia? Do we intend him/her to die? Consider someone who is incompetent without an advance directive such as the schizophrenic who refuses dialysis. If we decide that this causes repeated distress, as the patient needs to be retraint and/or sedated and even perhaps anaesthetised and decide not to proceed, is that the same (morally/legally) as shooting him? If a thrombophyllic patient who despite multiple pulmonary emboli and a ruptured cerebral aneurysm, is needlephobic and will not allow her (blood) clotting to be checked, are we intending a PE or brain haemorrage? The invasiveness, intrusivesness, pain and distress of a treatment or test are as much a feature of deliberations as how they can prolong life and to what degree they will improve matters -surely? So how can denying an unwanted treatment, or one which is 'inhumane' imply an intention to kill? Am I alone in imagining that the arguments in this area of medical ethics are muddled and concepts often deliberately misinterpreted? Competing interests: None declared |
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Gregory Gardner, Associate General Practitioner Cape Hill Medical Centre, Raglan Rd., Smethwick B66 3NR
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Opinion was divided as to whether Terri Schiavo was in a ‘permanent vegetative state’.One of the criteria of PVS is ‘no evidence of awareness of self or environment and an inability to interact with others.’[1] This was certainly not the case with Terri as numerous family members and caregivers testified. It is more likely that she was in a minimally conscious state as she had ‘appropriate smiling or crying in response to the linguistic or visual content of emotional, but not to neutral topics or stimuli.’ Furthermore, Terri was denied the kind of intensive rehabilitation which could have improved her condition, not least her swallowing abilities. The reason why congress intervened in the case was to instruct the courts to look at new evidence and massive conflicts of interest, an instruction which the judges chose to disregard. The courts had all the way along made presumptions biased towards her death. The United States judicial system is meant to be one of checks and balances, not a system where judges can pronounce death sentences on innocent people. An even more fundamental point however is not whether Terri Schiavo was in or out of a permanent vegetative state/minimally conscious state or fluctuating between the two but whether it is ever right to kill such people by starvation and dehydration or by any other means. 1 http://www.comarecovery.org/artman/publish/printer_ReportOnTheVegetativeState.shtml Competing interests: None declared |
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