12 • Ethics


END-OF-LIFE ENDING LIFE


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Can care extend to hastening death? Dr Niall Cameron considers some key ethical arguments in the debate over assisted suicide


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RECENT case heard before the Court of Appeal in London addressed a controversial and ongoing ethical debate in medicine today. Three appellants sought to change the law on


assisted suicide in order to allow a relative or doctor to help them end their lives. One had described his life following a catastrophic stroke as undignified, distressing and intolerable and said that he wished to end his life but was unable to do so because of his physical disabilities. The Court rejected their appeal. In his judgement, the Lord Chief Justice Lord Judge said: “The circumstances in which life may be deliberately ended before it has completed its natural course, and if so in what circumstances, and by whom, raises profoundly sensitive questions about the nature of our society, and its values and standards, on which passionate but contradictory opinions are held.”


This case and the furore surrounding the


Liverpool Care Pathway have refocused the attention of the media and public on the questions of how patients at the end of life are treated and whether they should be allowed or assisted to end their lives prematurely. The aim of removing or at the very least minimising the distress that can be experienced by dying patients unites all health professionals. Despite the best efforts of palliative care, this remains an aspiration we are far from achieving and may be unable to achieve for every dying patient. It is not hard to envisage a situation as described above where the quality of life becomes so grim, so desperate, that death appears preferable. Shared decision-making at the end of life raises many challenges and the associated


ethical issues can give rise to some of the most difficult and controversial questions that doctors face. The temptation may be to avoid becoming involved in what can be an emotive and highly charged debate, viewing the issue as too complex, too sensitive and one in which we as individuals lack expertise and confidence. Doctors may prefer to remain neutral, avoid becoming embroiled and allow regulators, politicians and the courts to take the lead. But it is likely that all of us will have direct


experience of patients at the end of life. We will have been involved in decision-making processes and will have encountered the ethical conflicts that can arise. It is this direct involvement and experience that I think permits and, arguably, requires health professionals to contribute to this debate and why the public and politicians look to us to inform the discussion.


Although an article such as this cannot do


justice to the full scope of the debate, my intention is to set out some of the key ethical issues that inform the discussion and need to be considered by us all.


My body, my choice No simple route map can help us navigate through this moral maze but the approach developed by the American bioethicists Beauchamp and Childress remains highly influential. They suggested consideration of four prima facie duties: respect for autonomy, beneficence, non-maleficence and justice. Active reflection on these principles could


offer an approachable, replicable and inclusive analytical framework that could help doctors make reasoned decisions when faced with an ethical dilemma. The attraction of such an approach is clear, but when you attempt to


address what might appear to be a relatively unambiguous moral dilemma, it becomes evident that the principles can compete for priority. Given the social environment in which they were developed, it is perhaps not surprising that the individual’s right to self determination expressed in the principle of autonomy has emerged as the over-riding principle trumping all others. This principle was articulated by the presiding judge in a landmark 1914 court decision (Schloendorff v. Society of New York Hospital): “Every human being of adult years and sound mind has a right to determine what shall be done with his own body…”. The principle of autonomy generates a


number of rights: the right to control personal information (confidentiality), the right to make decisions about medical treatment (informed consent) and the right to refuse treatment even when this seems irrational to others. Respect for these rights also informs the


actions we can reasonably expect of others. It follows that doctors have a duty to respect an autonomous patient’s wishes and to maximise their autonomy wherever possible, and should not interfere in any way that restricts the autonomy of an individual. The introduction of advance directives reflected a desire to preserve the right to autonomy even when an individual has lost their ability to be involved in decision making. Most often these directives attempt to anticipate end-of-life issues and specify what treatment the individual will accept and what treatment they would decline. Respect for autonomy is not only an ethical but a legal requirement and it has been clearly established that treating a competent individual against their wishes or as described in an advance directive constitutes assault.


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