Trial may advance demands for legal euthanasia: Advance directives could give patients the right to be allowed to die passively. Ian MacKinnon reports

NO ONE disputes that euthanasia is practised by doctors in Britain's hospitals every day. Established medical practice holds it entirely proper that the suffering of incurably ill patients should be relieved, even to the point where it shortens life. The moral and, it seems, legal question turns on a doctors' intentions.

Nigel Cox's mistake appears to have been that to end Lillian Boyes's suffering he injected her with potassium chloride, which has no pain-killing properties, betraying his intentions. Had her death been due to unprecedented doses of the painkiller, Diamorphine, she was receiving, there would have been no case.

Paradoxically, some believe the distress over Dr Cox's conviction will form a watershed that will advance calls for the legalisation of voluntary euthanasia as the public and politicians recognise the dilemma doctors encounter.

Ludovic Kennedy, the broadcaster and vice-president of the Voluntary Euthanasia Society (VES), says the time is ripe. 'The public, shocked by the verdict, is now ready for a change in the law. So for their own protection is the medical profession,' he said.

But a row is brewing over the attempt this autumn to introduce a Bill in the Lords giving legal support to 'advance directives', documents allowing people to stipulate that if illness prevents them expressing their wishes they should be permitted to die without treatment, dubbed passive euthanasia. Directives exist already, but supporters say the Bill would ensure that doctors could follow patients' wishes without fear of legal action. However, 60 MPs have signed a motion condemning the proposal, which they say would legalise 'killing patients by starvation and dehydration'.

That opponents reacted so quickly reflects the emotions euthanasia stirs and the alarm sparked by advance directives, seen as a half-way house to voluntary euthanasia. The euthanasia camp is adamant that advance directives are a separate concept - not to be confused with voluntary euthanasia, where a doctor actively ends a life at the patient's persistent request.

But these are merely the opening shots in an argument which sees both sides ready to tap society's most profound fears. Opponents link advance directives with voluntary euthanasia, and even involuntary euthanasia, where doctors take it upon themselves to take life in what they think is the patient's best interests.

'Clearly this is the first instalment to full-blown euthanasia,' Luke Gormally, director of the Linacre Centre for Health Care Ethics in London, said. 'Once advance directives are given legal force, doctors, by planned omission, will be able to bring about the death of a patient.

'Doctors will then say that to aid someone's death is not morally different from voluntary euthanasia, 'Let's have lethal injections because in many circumstances it's more humane than starving someone to death'. Once there, you'll not be able to contain it, and it's a short step to involuntary euthanasia. That's what the promoters of advance directives inherently want,' he said. John Oliver, VES general secretary, disagrees. 'Advance directives are a separate issue. At the moment patients can refuse medical treatment. We want to extend that to the time when they are no longer competent. This allows people to have control over their life. It would recognise what already happens in hospitals every day and clarify the law.'

However, Peggy Norris, a former GP and chairwoman of Alert, an anti-euthanasia group, said the law was quite clear and that any change would be detrimental.

'You would be giving the doctor the power to kill that patient. Doctors have one job: the care of their charge. It's too dangerous to allow them otherwise. The law protects the citizen and people who are ill or incapacitated must have the same protection. Advance directives are a rent in the tent, they remove the protection of the state not to be killed by the doctor,' she said.

But Mr Oliver views it differently. 'MPs have been duped by a small minority of fundamentalists into thinking the Bill is not about allowing people to die with dignity, but about active euthanasia.'

Lord Winstanley, chairman of an all-party group of 200 parliamentarians who support voluntary euthanasia, concedes the Bill is partly a 'gradualist' strategy.

The VES points to opinion polls which show that 75 per cent of people support a change in the law. 'All we are asking for is choice,' Mr Oliver said.

But according to Mrs Norris advances in palliative care make possible relief of symptoms in up to 95 per cent of cases, though she conceded there were some 'very intractable' cases.

However, it is the fear that extremely ill patients might be pressurised by unscrupulous doctors or relatives to seek an end to their suffering if euthanasia were legal that also spurs Mrs Norris.

'When you are ill you are very, very vulnerable,' she said. 'It may require a lot of work by medical staff, but they have to do it. We've got to have a professional ethic. We can't afford to water that down. We can't give doctors an easy way out. It's too dangerous, for the patient, for society, to make exceptions to allow one group of people to kill.'