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Bob Michell is a veterinary surgeon and lay member
of the Royal Pharmaceutical Society’s Council; these are
his personal views
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The Broad spectrum feature is
open to any reader. Contributions of around 1,100 words commenting
on topical issues
may be posted to Graeme Smith, managing editor, or
e-mailed to graeme.smith@pharmj.org.uk for consideration
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To begin at the beginning: thou shalt not kill. No ifs, buts or exceptions. The sixth commandment, the first of three still enshrined in criminal law, is explicit and unambiguous.
Britain retains established churches,
and bishops are disproportionately represented in the House of Lords,
but this is now a secular, multi-ethnic country, with only a minority
actively practising any religion.
Killing as a crime, rather than a sin, has exceptions: soldiers are expected
to kill and, increasingly, the police are forced to do so. The word remains
repellent, suggesting violence or butchery. Vocabulary is second only
to residual religious inhibitions in distorting debate on end-of-life
issues. Despite the sixth commandment, in time of war archbishops consecrate
the duty of our soldiers. Suicide is no longer a crime.
What rightly worries most citizens is not killing per se but murder.
Soldiers do not murder in battle; there is no personal motive except
duty and survival — which is also a potential justification in
civilian courts considering self-defence or manslaughter. “Acting
under orders”, since the Nuremburg trials, and despite recent events,
does not justify killing in cold blood.
The terms most frequently applied to end-of-life issues, “assisted
suicide” and “euthanasia”, each bring negative connotations.
These are reinforced by the increasing unfamiliarity of death. Until
some 60 years ago almost everyone saw people die — at home, in
the street or in hospital. Today even many doctors have seldom seen their
patients die — unlike veterinary surgeons.
Few vets would dissent
from the view that when there is no other escape from irreversible suffering — not
just pain — it is a great privilege to have this clinical choice
available: to be able to administer this final act of compassion where
no other release will suffice. Euthanasia means “a gentle and easy
death” and pets are far more likely to experience it than their
owners.
If, as a vet, I had allowed our dog to suffer in the way that the law,
despite superlative palliative care, forced my wife to suffer during
her terminal torment by pancreatic cancer, I would have been liable to
disciplinary action for perpetrating cruelty by omission.
The combination
of side effects of medicines, some potentiated by jaundice and hepatic
and renal failure, supplemented the suffering associated with her underlying
disease with a loss of the ability to communicate, personality disintegration
and paranoia; she became a passive body in nappies, receiving enough
drugs to control pain, although not all the time, and to render her
both confused and semi-comatose.
Yet the law did not allow the tortured semi-coma
to be eased into permanent peace despite the absolute certainty that
no form of recovery was feasible. More than once she said “the
birds are singing”, remembering how they sang a year earlier when
we eased our dog into permanent peace at sunset. It was what she craved,
and what the current law denies.
I see a bishop nodding wisely with a knowing smile — “but
we set a higher value on human life”. I agree. This is exactly
why we should no longer tolerate the obligation to impose greater cruelty
than we would accept for any other species in the clinical management
of death. If laboratory animals experienced similar deaths, the Home
Office would prosecute those responsible and protesters would stretch
from Parliament far beyond the boundaries of the London congestion charge.
We operate an irrational dual standard and turn a blind eye to the consequent
suffering. Modern medicine can postpone death and alleviate some of the
suffering of the terminal stages of life. But by sparing us from one
death it may consign us to another, far worse one. Purgatory, once the
place where sins were purged after death, has now been imposed on many
as the final stage of life.
Ultimately, clinical intervention is curtailed by laws opposed by the
great majority of our people. In a democracy, that is an appalling outcome
of legislative arrogance, and an impediment to our humane duty to those
who suffer against their will.
Among the arguments routinely wheeled onto the barbican is mistaken choice — by
choosing euthanasia we might forgo a miraculous recovery. But every adult
takes decisions that are irrevocable and makes choices that, if mistaken,
may even have fatal consequences. Every choice means that we have rejected
an alternative; it is the price of freedom.
The argument that those who are vulnerable may be pressured in their
decisions is entirely theoretical; as Ray Tallis, professor of geriatric
medicine at the University of Manchester, remarked on Radio 4 recently,
when you examine what happens where the law has already changed, those
taking the decision are perfectly clear about their wishes.
Of course we need to consider the feelings of doctors, especially those
with a deep moral aversion — although governments do not even blink
to consider the feelings of servicemen when they are ordered to embark
on mass killing. Indeed health professionals may already have to undertake
tasks which ar repellent for them but essential for the welfare of their
patients.
Vets also have to take life in harrowing and even unnecessary circumstances — for
example, the appalling, unprecedented and unnecessary surfeit of slaughter
imposed by the Government during the 2001 foot and mouth disease epidemic,
still the most expensive and inhumane peacetime folly in our history.
It is not death that most people fear, but the circumstances of death.
With all the rhetoric about patient choice there is no more important
choice than this; we cannot control the length of our life or the cause
of our death but we should be allowed, as far as possible, to control
the circumstances.
The question is no longer why patients should be allowed
this choice but why it should continue to be denied. If your pancreas
is shot through with malignancy, your abdomen stretched taut by the manifold
consequences, why can pain killers only be used to postpone the inevitable
instead of ushering it in with tenderness and dignity?
Sadly, the proponents of palliative care and of assisted dying often
confront one another’s views with tribal hostility instead of accepting
that, ultimately, many patients will need both. It is not life, but the
quality of mercy that should be sacrosanct.
Finally, back to vocabulary. Listen to the bereaved after every murder
trial, major accident or medical tragedy: what they crave is closure.
Not a poetic word, but from the first mingling of DNA, every life story
which opens must eventually close. Let us talk about life closure, and
how, with appropriate safeguards, “assisted closure” could
make it less barbaric. |
The
Pharmaceutical Journal