about acute depression being a mental illness and the desire for suicide it sometimes engenders therefore being the result of an abnormal psychological state, it does have to be said that for some people life is intolerable. If that is the case, there may not be a strong argument to prevent them from committing suicide, or even for criticizing them posthumously if they succeed. In other words, there is a moral dimension to the argument that suicide, in these circumstances, is not necessarily wrong and that attitudes towards it should change.
It is therefore not necessarily wrong for someone to whom life has become intolerable, for instance through continual pain, to commit suicide. What is wrong is to expect them to do it in order to relieve the obligation of their care from their family or from society at large, or to ask someone else to help them to do it. And therein lies the rub, for it is not easy to commit suicide if one is already very frail. This might encourage people who had not yet reached this condition to contemplate suicide before they became too incapacitated to carry it out.
That is a problem answered to a considerable extent by the idea of having legalized euthanasia. Obviously real safeguards would have to be put in place. Doctors could not act without another doctor, or health professional, or some other person, witnessing the request and formalizing it in some way. People of sound mind would then be able to take control of their own lives and deaths. What argument can there really be against such a system, properly designed with protection in place for individuals and protection, legal and ethical, for health professionals?
The answer has to be that it is simply wrong to ask someone else to kill you. If an individual wants to commit suicide, sad though it is, that is understandable. One could even argue that it is their right to do so, especially if they are terminally ill already and however traumatic for everyone left behind. But to ask other people to do it for you, because you lack the determination or because you want to wait to the last possible moment when life seems truly to have nothing more to offer, seems very hard. Suicide may not always be wrong. But murder–even with the best of motives, and by request–is. The role of a doctor is to heal and to care, not to kill. Crossing that line is very difficult to justify. It asks doctors and other health professionals to go against everything they have trained for. However critical we may be of the tendency within our healthcare systems to preserve life in all circumstances, asking health professionals actively to seek the death of another human being is asking them to lose their respect for human life in a quite fundamental way.
Yet it appears that public opinion has gradually been moving towards favouring mercy killing. From the beginning of the 1990s, attitudes began to change in the Western world. According to polls carried out for the Boston Globe (November 1991 and onwards), 64 per cent favoured physician assisted suicide for those terminally ill patients who requested it. Of those under 35, 79 per cent were in favour. Question 119, the Washington initiative to legalize physician assisted death, was not in fact carried. But it raised questions about the role of doctors in keeping patients alive unnecessarily, and in an undignified way, as well as issues about whether it was a major conflict for physicians trained to preserve life to assist willingly and knowingly in procuring death. Yet the physician who assisted in the suicide of two women (painfully but not terminally ill), Dr Jack Kevorkian, who was arraigned on charges of murder but without specific charges being brought against him, had a preliminary ruling in his favour in Michigan in February 1992 and continued to ‘assist’ patients commit suicide thereafter. In the UK, we are beginning to see newspaper reports about people going to Switzerland to receive physician assisted suicide, because they cannot get it here. So the pressure is there. Many people want to be able to request euthanasia ‘when the time comes’.
Although there are considerable moral dangers in such a system, I believe that we will see limited euthanasia in Britain in the next decade unless a real moral debate takes place and those who are opposed to it argue hard against it. Even if this happens I believe that we will still see physicians being allowed to give terminally ill patients the wherewithal to commit suicide if they are convinced that this is what they want. The climate of opinion is changing. What we need to think about is to what extent this is because of people’s fear of growing old and helpless, their fear of the disintegration of self in old age, and society’s increasing unwillingness to accept that it has to pay for the care of the extremely frail and dependent.
Advance Directives
The arguments against the projected changes include, firstly, the view that asking doctors and nurses actively to kill patients is wrong and creates the wrong value system for a healthcare service of any kind. It may be the case that healthcare professionals do not need to strive to keep patients alive, but that is very different from actively killing their patients. Secondly, that suicide itself is not wrong and that an elderly or very frail person committing suicide is not necessarily to be disapproved of if it is done by their own hand rather than by another’s. Acceptance of this view should lead to a change of perception which might allow people to realize they can do it for themselves, and even be helped by being given the means in particular circumstances, without having to ask someone else actually to kill them. Thirdly, a rider to all this is the need for us as a society to develop a system of advance directives, whereby people can make choices for themselves about whether they want to be treated if extremely ill or when they can no longer make decisions for ourselves.
Such a system is in place in the USA. The PSDA (Patient Self Determination Act), a piece of federal legislation, came into force in December 1991. This requires all healthcare institutions, HMOs and services in receipt of federal funds to ask patients the question upon admission or enrolment about whether they have any kind of proxy or advance directive for what is to happen to them in the way of healthcare decisions if they become incompetent. At the same time, there is legislation in most US states that covers either healthcare proxies or advance directives, recognizing them in law and therefore in a sense approving their use.
There has been, rightly, increasing pressure to have a universal system of advance directives in the UK. The UK government has finally signalled, after a ten-year campaign, that there will be legislation to enforce so-called living wills via the draft Mental Capacity Bill, published in June 2004. This would apply both to those nearing their deaths, such as those who are frail and elderly, and to those who are or might become incapable for other reasons, such as those with enduring mental health problems, so that they can consent in advance to the treatments they might choose to have, or decide not to have, if they were well enough to make a decision. Some of the American evidence suggests that two separate factors are at work here. The first is a genuine desire to see self-determination for the very old. People must take responsibility for themselves, and must be encouraged do so before incapacity sets in. The other factor, which is certainly echoed in the UK debates, is the vast cost of paying for healthcare of the very old. The general view is that everything that can be done for a patient must be done, and there is a corresponding fear of being sued if any stone is left unturned, or any intervention left untried. If people could be persuaded to use advance directives, or appoint agents, there might be less use of expensive resources by the very old and very sick.
The fear of litigation in the USA is real and is growing in the UK. Though actual litigation is less common than the fear of it might suggest, it does have a powerful effect on behaviour. In the USA it is that pressure that has led to an increasingly strong argument for individual patients to have their own advance directives. State statutes on treatment directives give physicians a guarantee of civil and criminal immunity if they withhold or withdraw life-sustaining treatment relying in good faith on a patient’s advance directive. So, the argument runs, encouraging the use of advance directives will lessen the chance of litigation, allow for real patient autonomy, and arguably save costs.
But, if we are to move to a system of advance directives, then, as a society, we have to think quite differently about our health and social care systems. For the first time, with the exception of palliative care and hospice services, we will have to give far greater thought to the question of suffering, for despite the success of the hospice movement, suffering is barely part
