Letter: A middle way to care for the dying

Sir: Angela Lambert ('Let them go in peace', 14 December) is right to wonder about 'the medical practice and ethics which determine . . . painful and unwanted prolongation of life'.

The first example she quotes, however, gives no evidence as it stands of meddlesome medicine at the end of life. The picture is of an 'infinitely old, chalk-white' woman who is unconscious and peacefully dying over several days, surrounded by a loving, attentive family.

No evidence is given that the process of death had been 'intolerably drawn out' by the medical profession. Of course, it may have been; but Ms Lambert tells her readers nothing that would substantiate such a view. Could it be that the article is about Ms Lambert's distress when in the presence of death? Something that is very natural but hardly an objective reason for lambasting the medical profession.

Her second example is of a young woman experiencing prolonged grief - possibly pathological - following her mother's death from cancer a year ago. Is Ms Lambert suggesting the euthanasia (deliberate death acceleration) would have prevented the young woman's grief? Grief is inevitable after a major loss, and it is difficult to be with someone in grief, particularly if prolonged. Or is Ms Lambert making a plea for a grief-free world?

Her third example is of 'someone over 75' who is suffering from blackouts because of a very slow pulse ('heartblock'). It is a condition that is totally alleviated by the insertion of a cardiac pacemaker. Surely Ms Lambert appreciates that the insertion of a pacemaker requires the consent of the patient? To label doctors as 'well meaning but less merciful' because they offer an octogenarian a pacemaker is unreasonable.

Ms Lambert concludes by asking if there is a middle way between death intolerably drawn out and euthanasia. The answer is yes, there is.

Medical ethics stem from a series of dichotomies: seeking to sustain life but recognising the inevitability of death; balancing the burdens of a particular treatment against its potential benefits; weighing up the demands and needs of the individual against the demands and needs of society. A doctor is not obliged by ethics or law to preserve life at all costs. In a famous case in the late 1950s, Lord Justice Devlin stated:

A doctor who is aiding the dying does not have to calculate in minutes, or even in hours, and perhaps not in days or weeks, the effects upon a patient's life of the medicines he administers or else be in peril of a charge of murder.

The middle way may not always be easy to achieve, and certainly not instantly. However, recent moves to include ethics, communication skills and palliative care in the curricula of all health-care professionals should result in less meddlesome medicine, and better pain and symptom relief in the dying. On the other hand, if Ms Lambert's goal is a life free from all suffering and all grief, she will continue to be disappointed.

Yours sincerely,

ROBERT G. TWYCROSS

Macmillan Clinical Reader in

Palliative Medicine

University of Oxford

Oxford