The producers of BBC1's Holby City (10 and 17 October 2006) are to be congratulated on identifying a serious issue affecting not only medical ethics but also society as a whole - namely, how should we deal with people who are terminally ill and who want to die and - but here comes the rub - want medical help to do it? This is becoming an increasingly serious issue as, on the one hand, advances in medical science prolong life and, on the other, patients are coming to see themselves as 'consumers' and want their health care tailored to their personal requirements.

It is a pity therefore that the programme makers allowed themselves to be swayed into portraying just one side of the story. The characterisations - a strong-willed patient (Gina) who wanted to commit suicide, a panicking and incoherent husband (Elliot) who didn't want her to do it, an intolerant doctor (Connie) who eventually agrees to go to Switzerland to support Gina, a Swiss apartment (the location for the death) looking out over lakes and mountains bathed in glorious sunshine, a statement by Gina to the effect that 'we ought to have this sort of thing in Britain' - all pointed very clearly to a one-sided message being conveyed rather than to an important issue of our times being exposed for debate. Let's look therefore at the other side.

Notwithstanding the rather obvious bias, there were some clear, if unintended, indicators in the programme, for those who took the trouble to look for them, that aiding and abetting suicide is not the way forward for terminal illness. The key one was Gina's personality. She was a strong-willed woman whose problem was not so much the symptoms of her illness (motor neurone disease) as the restrictions which it placed on her life. What we were seeing in Gina is a phenomenon which doctors see in a small minority of terminally ill patients - it was not the illness itself which was causing her suffering so much as the fact that she had lost her ability to enjoy life as she used to.

This 'existential suffering' is, of course, very real for the person concerned, and no one is trying to suggest otherwise. But it is important to see it for what it is because it points to something which is not widely recognised. Many people, when they are asked whether terminally ill patients who are "suffering unbearably" should be given help to end their lives, see suffering in terms of agonising pain and physical distress. In fact, most serious requests for euthanasia come from people whose problem is the fact of their terminal illness, with which they cannot come to terms, rather than its symptoms, which can be readily controlled by modern medicine. Anyone who looked at Gina could see that she was not in distress, but rather frustrated at not being able to get about and enjoy life as once she had. Yes, that's sad - very sad. But it does beg the question - is frustration with illness a sound reason for considering changing the criminal law, with all the risks that that involves?

Some people might say it is, and they would probably argue that, provided there are strict safeguards in any euthanasia law, there would be no consequent risk to anyone else. This 'balance of harms' issue lies at the heart of the 'assisted dying' debate. We are told that the law as it stands is causing some people to suffer because they cannot have help to commit suicide. But the potential benefits to such people of changing the law have to be balanced against the potential harm to others. It is simplistic and naïve to believe that, because a new law would not oblige anyone to have euthanasia but simply enable those who wanted it to end their lives, it could have no harmful consequences for others. Those who care for the terminally ill know of the often-severe stresses which surround this period of life - the transient depression which makes a person want to die at one time and to live at another; the feelings of internalised guilt which make a dying parent reluctant to impose a personal care burden on children or to eat up their inheritance in nursing home care. Anyone living in the real world knows that these fears are more than speculative. Experience - for example, of abortion law - shows all too clearly that laws are not like precision-guided missiles: they have a habit of causing collateral damage well beyond the intended target area.

That aside, there might perhaps have been a respectable case to be made for a euthanasia law 30 or 40 years ago, when doctors could do little to relieve the pain and distress of terminal illness. But there is a terrible irony here - in that advances in the science of pain relief and in palliative care generally have taken place alongside a rise in pressure for patient autonomy, so that demands for medically-assisted dying have become more strident as they have become less justifiable. We need to recognise that patient autonomy is not just another branch of consumerism. It exists in order to protect sick people from unwanted treatment, not to give them the right to dictate the treatments they receive, which must be based primarily on medical science and ethics. And we also need to recognise that, whatever may have been the case when our parents and grandparents were alive, we are now living in a world where the distress of dying - and that includes the psychological and spiritual distress as well as the physical - can be treated if - and this is the crucial point - the patient will accept the treatment. Evidence from Belgium, where euthanasia was legalised four years ago, shows that, where applicants are required to undergo a course of palliative care before confirming their decision, most of them change their minds and decide that life is worth living after all. Anyone who has seen good palliative care in action knows that euthanasia is yesterday's answer to today's question.

So, to return to Holby City, full marks to the producers for raising a very important issue, but nil points for not treating it in a balanced and serious manner and exposing the arguments on both sides.

Care Not Killing

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