Euthanasia and the EU
The European Journal - May 2002
The Journal of the European Foundation
A number of delicate issues have been raised or debated in the European Parliament recently, including the EU's global campaign against the death penalty, the controversial issue of EU research funding for experiments on spare, IVF discarded human embryos and the cloning of human embryos for therapeutic stem cell harvesting. The most recent is a proposal to debate an emergency resolution questioning the new Dutch law on active euthanasia, which came into force on 1 April. This effectively legalised a controversial practice prevalent for two decades involving an estimated 5000 'mercy killings' a year.
So far, the EPP-ED group, to which the British Conservatives belong, has rejected opposing the change in the law directly after strong lobbying by both sides, including the anti-euthanasia campaigners who were afraid the EP might defeat it and thus send the 'wrong' signal to Member States which are wavering on this issue.
When life begins remains controversial, and now where it ends is becoming the focus of debate. As a medical student, I was taught some simple but fundamental principles of medical ethics; respect for the sanctity of life, "primus non nocere" (first do no harm); "thou shalt not kill but thou shalt not strive officiously to preserve life", and respect for non-malificence and patient autonomy.
This is in contrast to the better-known Diane Pretty case where she requested harmful (fatal) treatment to be administered, and the British courts refused to give her husband immunity from prosecution for a crime that carries a maximum 14-year jail sentence. This is the very different from active voluntary euthanasia, which I strongly oppose, and which Dutch law, unfortunately, now sanctions . The late Diane Pretty took her appeal to the European Court of Human Rights in Strasbourg where she tried to claim that a denial of her "right to die" constituted a violation of her fundamental rights. I have never been convinced of the need for active euthanasia.
British doctors, by and large, are quite comfortable with the interdiction against active euthanasia, but are perfectly willing to practice passive euthanasia. This can be voluntary where the patient is able to consent, or even involuntary if the patient is unable to consent due to dementia or coma. It is subject to close consultation with the relatives and other senior medical colleagues. This is seen as good medical practice, affording patients the opportunity to die with dignity.
Moral purists would argue there is no difference between masterful inactivity of withholding treatment, including the switching-off of ventilators, and the more active Dutch or US Dr Jack 'Death' Kevorkian-type killing method. Dr Kevorkian is now serving a 25-year prison sentence for second-degree murder after conviction for assisted suicide of over 100 terminally ill people. However, to a bedside clinician these two versions of euthanasia feel very different owing to one being manifestly successful immediately after administration of the lethal dose, whilst the other involves nature taking its course over an indeterminate period of time. The fact that the purpose of a change in regime is primarily designed to prevent prolongation of suffering, rather than bring about immediate death, is also difficult to ignore.
This debate has hotted-up on the other side of the Atlantic as in April a US Federal Court declared unlawful an attempt by the US Government to intervene against a 1997 Oregon State law allowing physician assisted suicide. It was the only US state to have such a law. John Ashcroft, the US Attorney General, issued an order backed by the Christian right-to-life lobby on the basis that participating doctors were overstepping the ethical boundaries of their profession (even though the patient needed to self-administer the fatal drug) and that federally-controlled drugs would necessarily be used.
The law, which was not contested by his immediate predecessor from the Clinton Administration, Janet Reno, was introduced to address the issue of uncontrollable pain. According to opponents, however, of the 27 cases terminated not one fell into that category. Rather, all 27 were for psychological and social reasons, leading to claims that the eminently treatable condition of depression was the main reason for their death. Opponents have also claimed that this is the case in Holland. Mr Ashcroft's Directive established in writing for the first time the 'safe harbour' principle that opiates (only morphine is allowed in the US) could be used as painkillers even at doses that might unintentionally kill the patient as a side effect, in order to counteract the euthanasia lobby which claimed people were dying in pain as doctors feared using high enough doses for pain relief in case they might be prosecuted for homicide.
This clarification is consistent with current British doctrine; and this practice has never been challenged in the UK. Moreover, the UK has a well-established palliative care hospice movement, expert in pain relief and permitted to use the more potent drug diamorphine (heroin); unlike the more restricted US analgesia practice. The existence of palliative care as a specialty would be challenged in the UK were euthanasia introduced. This is suggested by the fact that there are virtually no palliative care specialists or beds left in the Netherlands.
It has been said that the measure of a nation's civilisation is how it treats its old and sick. In my view, Holland does rather badly on that. Of course, there are obvious advantages for politicians in not having to pay for expensive cancer treatments or palliative care centres or nursing home beds for the frail, sick or demented. Besides, importantly this is not a constituency with voters who will complain! Who knows how many euthanised Dutch citizens might have subsequently changed their minds or how many of these citizens were in fact suffering from a depressed suicidal state of mind (potentially reversible with antidepressants) when asked to sign their own death warrant by some uncaring relative anxious to inherit their property or spare any further expensive medical treatments from the family budget? Who knows, for that matter, how many were sufficiently cognitively unimpaired (i.e. not dementing or suffering from delirious condition all too common in advanced terminal conditions) to be fit enough to make such a critical final decision? Once they are dead this becomes a statistic that cannot be calculated.
Elsewhere in the world practice varies considerably. Australia's Northern Territory briefly had a Rights of the Terminally Ill Act allowing active euthanasia but the Federal Parliament repealed this in 1997. Switzerland, although its Parliament rejected a Bill, tolerates assisted suicide without motives. In Colombia the Constitutional Court has ruled that, in cases involving the terminally ill, it should be unpunishable.
One of my biggest objections to the Dutch Act, and similar legislation passed by the Belgian Senate last year, is based on the frequent allegations that doctors and relatives have frequently breached the safeguards built in. I fully accept that patient autonomy theoretically allows the right to suicide, which has been decriminalised in the UK, but the problem is always determining how competent the patient is to make such a decision which might be clouded by depression and outside influences. Besides, in Holland children as young as 12 can make such a request with parental backing (and from 16 without). I believe it is degrading for a doctor, as a healer, to initiate the act of death. To my mind, the taking of human life should never be compared to a veterinary act like putting down a dog. Moreover, euthanasia offends against the doctrine of the sanctity of life, already badly compromised by the widespread legalisation of abortion on demand in the '60s and '70s.
Although advocates for abortion in the UK in 1967 claimed it would only be used in hard cases, in practice, it immediately became available on demand. Exactly the same has proven to be the case in Holland with euthanasia. A 1990 study revealed that two thirds of cases were carried out not for intractable pain at all but for 'low quality of life'. In 1996, Dr Hendin testified that more than 1,000 cases per year did not even have the patient's approval, this was the case with its use on the comatose, the demented or handicapped neonates, even though the current law now outlaws this by requiring a clear statement from the patient that the choice to die is rational and reasoned. A second medical concurring opinion is required, which is then reviewed by a regional commission, but alas only after death! Inappropriate terminations may be reported but this is entirely at the Commission's discretion with no involvement of the public prosecutor.
The UN Human Rights Committee of independent experts criticised the Dutch model, accusing it of having the potential for routine and insensitive mercy killings, where pressure could be brought to bear to avoid the legal safeguards. This is not helped by a statement immediately after the law was passed by the Dutch Health Minister that elderly patients "tired of life" should be supplied with a suicide pill, as evidenced by the 1995 case when such a pill was supplied to former Senator Brongersman by a Dr Sutorius, although he was absolved as he was said to have acted with "compassion" !
Even more alarmingly, Dutch law, unlike Oregon's, says nothing about imminent death, only insisting on the more subjective "unbearable, interminable suffering" test, which of course includes severe psychiatric, and therefore potentially treatable, conditions. Theoretically, the Dutch law requires that the patient be resident in Holland, but this is unenforceable. This is also, in my view, the reason why the European Parliament might claim the right at least to debate this issue. The new law contravenes Article 2 of the 1950 European Convention for the Protection of Human Rights and Fundamental Freedoms on the protection of life.
There is the very real possibility of 'death ambulances' crossing national frontiers. It is feared that these will ferry elderly patients from, say, neighbouring Germany (which still remembers and fears Nazi era euthanasia), where it is strictly proscribed, to Holland for termination. This is rather like the traffic of Irish girls coming to London to terminate their often advanced pregnancies, which has made the UK the abortion capital of Europe and has helped it to develop a multi-million pound 'abortion industry'.
This fear of 'euthanasia tourists' has surfaced in Italy when a Turin magistrate raised the spectre of an Italian suspected of assisting the passage to the Netherlands of ill people to die. It is also my view that the Dutch government, as shown by the disappearance of palliative care in their country, has totally ignored advances in modern pain relief therapy, undermined training and research in this vital area and lowered medical professional dignity by allowing doctors to participate in an act which offends against its basic life-saving principle. This has been replaced instead by a culture of death. I sincerely hope that we in Britain never introduce such callous legislation over here.