END OF LIFE
by Dr Richard Vautrey
General Practitioner, Deputy Chair of the BMA General Practictioners' Committee, Vice-President Elect of the Methodist Conference and a local preacher in the Leeds North East Circuit
Mark 15: 33-37
How do you want to die? Have you given it any thought? I imagine the older you are the more likely you are to think about this, but the reality for most of us is that we’d rather not think about it. Benjamin Franklin famously said “In this world nothing can be said to be certain, except death and taxes.” It might be possible to avoid taxes, but none of us can avoid death. Yet something that effects us all remains largely taboo.
The most well documented death in the Bible is that of Jesus. Nowhere else do we see the anguish, pain and helplessness that can come with death so graphically described. However our view of Jesus’ death is coloured by our knowledge of his resurrection. We sing “death hath lost its sting” with gusto every Easter Sunday and as Christians we say we do not fear death, yet for many it is still something we inwardly worry about, try to postpone, and hope that when it comes it will be swift and painless.
Despite it being the most natural thing that could occur, what happens at the end of our lives has become increasingly controversial. Around 500,000 people die each year in England, with 2/3rds being over 75 years old. Even though most people express a wish to die at home, almost 60% die in hospital, 17% die in a nursing or residential home, 4% die in hospices and only 18% die at home.
This means that few of us see death. It is something that happens out of site and is often medicalised. In many parts of the world, death is sadly an every day occurrence. Whether it be childhood illness, accidents or HIV and TB, deaths in young people are not unusual. However in our society you may not even experience the death of a grandparent until you are almost middle-aged yourself. It’s no surprise therefore that we don’t talk about death or dying.
When we do it is often with a fear of pain. We worry about being a burden to others, and in particular we fear long term disabling illnesses such as cancer, a stroke, heart or lung disease. As Dame Cicely Saunders, the founder of the modern hospice movement said, “How people die remains in the memory of those who live on”. Our understanding and our fears of death are often coloured by the experiences and folk-lore within our own family and friends.
It is these fears that have generated an increased interest in and debate of euthanasia, where someone other than the patient administers a fatal dose, and physician assisted suicide, where patients are assisted to end their own lives.
Those who argue for euthanasia believe that a competent individual’s rights should be respected when treatments are unable to prevent painful or distressing terminal symptoms. They argue that we are content to put a pet dog out of its misery, so why should we deny that to a man or woman with a terminal illness? However clearly the option of euthanasia impacts on the lives of others, not least those called on to administer a fatal drug.
It also has the potential to undermine the relationship between carers, both professional and lay, and patient. Seriously ill and vulnerable people, who may already feel a physical or financial burden on friends and relatives, may feel pressured in to choosing this option. This is what is often referred to as the “slippery slope” argument, something that was meant to be applied in a very limited way and with the best of intentions but which becomes much more widely used and potentially abused. The difficulties of effectively monitoring to ensure that euthanasia is not abused is accepted even in Holland were it has been estimated that up to six out of ten cases of euthanasia are not reported as they should be.
The arguments for and against assisted suicide are very similar although in this case the individual concerned retains control of the process. This crucial difference has led to calls for its legalisation in line with that of other countries and this gained some degree of support when Lord Joffe brought forward a bill in 2006. However even here, the majority of doctors were concerned that assisting patients to die prematurely was not part of the moral ethos or primary goal of medicine and would inevitably have a negative impact of the doctor patient relationship, and therefore opposed any change in the law.
Active and intentional termination of another person’s life is morally and legally different to the withholding or withdrawal of treatment. Medical treatment can be legally withdrawn when it is deemed to be futile or in the best interests of the patient to continue with it. This was the central to the debate in the Tony Bland case, a victim of the 1989 Hillsborough disaster that left him in a persistent vegetative state. His relatives and doctors asked for his feeding tube to be removed and this was supported by the court. This is an extreme although no longer rare case, but the basic principles are very similar every time a decision is made not to give antibiotics for a chest infection, to withdraw common drugs for heart disease, or agree not to resuscitate a person clearly at the end of their life.
It is now legally possible to record in advance what your wishes would be in such situations. Through an advanced decision, or living will, clear instructions can be left that you would want to avoid specific procedures or medical treatments if you were incapable of making such decisions at the time. However no advanced decision can force a carer to break the law, although they must always act in the incapacitated individual’s best interests. It is also hard to be certain, when advance decisions are made a long time before mental capacity is lost, and where medical advances have led to better and more successful treatments, whether the patient would have changed their mind.
As Christians we see God’s image in all people. We cherish and see value in all human life, and yet we also proclaim that we do not fear death. We have a duty to do all we can to meet the needs of those coming towards the end of their life, not just their physical needs in terms of pain relief and nursing care but emotional and spiritual needs too, what is often summed up as tender loving care. That’s something we can all offer and one time or other in our lives.
- Should we encourage everyone to make advance decisions or is it impossible to decide what you want before the situation arises? Is it appropriate to leave these decisions in the hands of medical teams and relatives?
- No matter how good palliative care is, a small number of people do suffer uncontrollable pain at the end of their life. Dr Nigel Cox was convicted of killing his patient Lillian Boyes who suffered intractable pain and begged to die. Can ending someone’s life ever be seen as acting with mercy?
- Has “death lost its sting”? How does Jesus’ resurrection colour our view of end of life care?