Death on prescription?

In some countries, a person administering enough drugs to kill an 85-year-old terminally ill cancer patient would be called a doctor. In this country, such a person came close to being called a murderer. Will we ever be able to live with...
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This is a story told by a family doctor. He was looking after a man in his late fifties who had been a lifelong smoker and had lung cancer. The cancer had spread through the man's lungs into his liver and his bones. He had had half of one lung surgically removed and was undergoing chemotherapy on the general ward of a London hospital, which left him nauseous, depressed and with profuse diarrhoea.

"He wanted to know how long the treatment would go on and how successful it might be. He knew the extent of his problem. He had severe pain in his bones - metastases [growths] in the bones are always the most painful - and he was on diamorphine," recalled the doctor. "He had several talks over two weeks with me, the registrar and the consultant. We also spoke to his wife. She is very nice and well educated so it was never a case of talking down to her but talking as equals, which is always easier, of course.

"The man said he would like to go as soon as possible. His wife was with him holding his hand - and it was agreed. Over 24 hours we trebled the amount of diamorphine. He was still alive so we doubled it again. He died 48 hours later."

Similar stories could be told by hundreds of family doctors across the country but yesterday this one chose to remain anonymous. After the Newcastle GP Dr David Moor narrowly escaped a murder conviction when his 18-day trial ended on Tuesday, colleagues who supported his outspoken stand have seen the danger of sticking their heads above the parapet.

For it became clear during the trial that Dr Moor was being prosecuted for what he said rather than what he did. He was charged with administering a lethal dose of diamorphine - pure medicinal heroin, that is - to a terminally ill cancer patient, George Liddell, aged 85. In interviews two years ago he had admitted to helping 300 patients die during the course of his 30-year career and - unwisely, as it turned out - gave enough details of Mr Liddell for the case to be identified and a prosecution brought.

In court, however, he claimed that all he had tried to do was relieve Mr Liddell's "agony, distress and suffering". In that case what he had done was no different from what GPs do legally every day, and the jury acquitted him. The judge, however, saw fit to punish him for the "silly remarks" to the press that had triggered the case by awarding one third of the costs against him.

The upshot, then, is a nasty case that has decided very little. Doctors are left to interpret the doctrine of "double effect" on which they rely in cases such as Mr Liddell's as best they can. That doctrine states that a doctor may hasten death by prescribing steadily increasing doses of drugs, provided the intention is to relieve suffering. Dr Moor crossed a legal boundary when he said his intention was to shorten life. While the outcome of the case has left the legal position unchanged, it has breathed new life into the debate about what some describe as the last taboo.

Everyone has to die sometime, so should we not do what we can to "ease the passing", in Dr John Bodkin Adams's phrase? [He was the GP charged with murder in the 1950s after benefiting under the wills of several wealthy widows who died unexpectedly in his care. He was acquitted.] Death, which a century ago was visible and present, has become a stranger in the modern world - hidden, aseptic and feared. How to achieve release from a terminal illness with dignity and peace has become a modern preoccupation - of the middle classes, at least. Support for euthanasia has grown, according to polls, from around 50 per cent in the 1950s to 82 per cent in the 1996 British Social Attitudes survey.

Enthusiasm wanes, however, with declining social class and advancing age. The poor and partly educated are much more cautious about ceding to the state power over life and death, and the old, who are most likely to benefit from a swift and painless end are, intriguingly, also those least likely to support it. Life grows more, not less, precious as it dwindles - a point often missed by supporters of euthanasia.

The orthodox view, put by the British Medical Association, is that growing public support for euthanasia is based on a misapprehension that pain and suffering at the end of life may be so severe that death offers the only release. The BMA's view is that there is no pain so great that it cannot be controlled with modern treatments. Hence there should be no cause to end life prematurely. But is this true? A vociferous minority of doctors challenge the BMA view on two main grounds - that it is hypocritical and that despite the advances in palliative care of the terminally ill, there are some for whom modern medicine can do nothing and who will die in great pain.

Dr Christopher Hindley, a GP in east London who works in a hospice, and claims to have assisted several patients to die at their request, says dealing with pain at the end of life has largely been solved. "It is amazing what we can do - pain has ceased to be a major problem. What people fear most of all is breathlessness, not pain. They don't want to suffocate. The palliative care movement admits that that is a very difficult symptom to deal with."

He describes the death of a friend, a woman GP in her late sixties, who had lung cancer. "I sat by her bed and in her last 24 hours she was fighting for breath. It was incredibly distressing for her and her nearest and dearest. We know that the only way to deal with breathlessness is to give drugs that suppress the respiratory system - that is, barbiturates as used in anaesthesia. But she was not given barbiturates because that was not the policy in the hospice where she died."

Those most likely to demand euthanasia, Dr Hindley points out, are doctors themselves, which should give us pause. They know how people actually die and demonstrate their lack of confidence in palliative care by asking for help to hasten the end. Dr Hindley believes that the double effect doctrine offers no more than a convenient defence behind which the practice of mercy killing can hide. "It is a bit of medieval sophistry out of line with modern thinking," he says.

The BMA, which has more than 100,000 members, counters that on the last occasion when euthanasia was debated, in 1997, it was overwhelmingly opposed. The meeting agreed, however, to include the words "for the time being", signalling an intention to return to the issue. This month the BMA is expected to agree new guidelines on withdrawing treatment at the end of life and is due to hold a debate on doctor-assisted suicide later this year.

The challenge for those, such as the Voluntary Euthanasia Society, who would see the law changed, is to frame a better one - that is, one which would reduce, not increase, the overall harm caused by the existing law. In Holland, which has pioneered the practice of mercy killing under strict guidelines, there has been something of a backlash with thousands of people now carrying anti-euthanasia cards warning that nothing should be done to end their lives prematurely.

One of the most disturbing cases, which jolted the resolve of even the most ardent supporters of euthanasia, involved a Dutch psychiatrist, Boudewijn Chabot, who admitted helping a healthy 50-year-old woman to end her life in 1991. He had agreed with her that she was hopelessly, irretrievably depressed after losing her two sons, both of whom died, two years apart, aged 20.

Dr Chabot was charged with malpractice, but acquitted after the judges accepted that a patient's psychological suffering was as valid a reason for seeking euthanasia as physical suffering. Critics, however, saw this case, more than any other, as exemplifying the "slippery slope" dangers of accepting the practice.

Holland and the US state of Oregon are the only territories where euthanasia is permitted. The BMA believes - and it is hard to disagree with it - that maintaining the legal distinction between hastening death and relieving suffering is critical to the trust that patients have in their doctors. Otherwise, they may come to be seen as agents of death. Vulnerable people with a terminal illness must be able to turn to their doctor in trust without fearing that the doctor could put pressure on them to end their lives.

Easing the passing of those at the end of their lives demands skill as well as sensitivity. Opponents of the present law, based on the double effect doctrine, claim it leaves doctors vulnerable and confused about what is permissible. But it does not. The intention to relieve suffering is clearly distinct from the intention to kill. The doctrine of double effect has the virtue of allowing doctors to bring life to a peaceful and dignified end without jeopardising patients' trust. It may not be the ideal option - no law can accommodate every eventuality - but it is the least worst. No other country has shown conclusively that there is a better way.