Autonomy was defined by Professor John Harris ... 'as the ability to choose and the freedom to choose between competing conceptions of how to live'.
A more qualified view of autonomy - what was referred to by some as 'principled autonomy' - was given to us by the Reverend Professor Robin Gill on behalf of the Church of England - namely , that 'the rights of the individual always go hand in hand with the duty of the individual to other people'. The same point was made by Dayan (Judge) Chanoch Ehrentreu, on behalf of the Chief Rabbi: 'Despite contemporary society's commitment to individual liberty as an ideal, it recognises that the interests of the individual cannot be separated from the interests of society at large'.
Yet another view of autonomy was given to us by Ms Alison Davis, National Co-ordinator of No Less Human, that “the concept of autonomy actually means that you should act in your own best interests, and best interest as traditionally understood means that things like preserving life, maintaining health, restoring health, minimising suffering ..are the sort of things over which we have autonomy”.
Applying these principles to the field of clinical practice, Professor Alan Johnson, Emeritus Professor of Surgery at the University of Sheffield, observed that 'the impression has been given that obeying patients wishes is the overriding ethical imperative for doctors. Of course it is important , but it is not paramount. If it were, I would have done many unnecessary operations in my time as a surgeon'
It is clear from the evidence which we took from representatives of religious organisations and from letters we received that many people believe that life is God-given and cannot in consequence be terminated by others, even on request. ... The Rev Professor Gill said that, while to Christians life is God-given, 'to secular people life is still a given by the people; you did not invent your life. Human life is in that sense something special and to be treated with care. Intentional killing is not something any of us should be taking lightly, whether we are religious or not'.
Another witness, Lord Walton of Detchant, who chaired the 1993/4 Select Committee on Medical Ethics, referred to 'society's prohibition of intentional killing, a prohibition which is the cornerstone of law and of social relationships. It protects each one of us impartially, embodying the principle that we are all equal'. Professor John Finnis of the University of Oxford saw this law as a 'bright line'. 'Though like other laws,' he said, 'it is not invariably respected, it is not in the least artificial or brittle: it rests on a rational principle that a person's life is the very reality of the person'. Mrs Michele Wates, a researcher and writer, took the view that the Bill would 'turn that principle on its head and establish in its place the principle that a person may invite others to kill them'.
It is necessary to consider also judgements given both by the House of Lords (2001) and by the European Court of Human Rights (2002) in response to appeals by Dianne Pretty. Mrs Pretty, who was suffering from motor neurone disease was paralysed from the neck downwards, though with her intellect and capacity to make decisions unimpaired, appealed against a refusal on the part of the Director of Public Prosecution (DPP) to give an undertaking that her husband, Brian Pretty, would not be prosecuted under section 2 of the 1961 Suicide Act if - as Mrs Pretty said she desired - he helped her to commit suicide. The appeal claimed inter alia, that the DPP's refusal was incompatible with Article 2 of the European Convention on Human Rights and that Section 2 of the Suicide Act was discriminatory because it bore particularly heavily on people whose physical incapacity required the assistance of others if they wished commit suicide. Both appeals were rejected, and Mrs Pretty died shortly afterwards of natural causes.
In giving its reasons for refusal, the House of Lords ruled that Article 2 of the ECHR, which enunciated the principle of the sanctity of human life and provided that no individual be deprived of life by means of intentional human intervention, did not imply the right of an individual to choose whether to live or die ...... also ruled that Section 2 of the Suicide Act was not discriminatory (because the Act conferred no right to commit suicide)....
Lord Joffe foresaw the possibility of subsequent amendments to his Bill, should it become law, to widen its scope. 'We are starting off,' he said, 'this is a first stage... I believe that this Bill initially should be limited, although I would prefer it to be of much wider application, but it is a new field and I think we should be cautious.' Expanding on this, Lord Joffe told us that, 'when we considered the opposition to the previous bill, we felt that there was such strength of feeling in the debate about extending it to younger people who had a long lifetime ahead of them that we thought it wise... To limit it to terminally ill patients who were already suffering terribly and had a short time to live. But I can assure you I would prefer that the law did apply to patients who were younger and not terminally ill but who were suffering unbearably, but if there is a move to insert that into the Bill I would certainly support it'.
....Professor Henk Jochemsen, a medical ethicist from whom we took evidence in The Netherlands, drew attention to ongoing debate in that country about extending the existing law on euthanasia to cover new categories of persons, including newborn babies and others without medical conditions who are 'tired of life'. We can do no more here than note that the bill if enacted, is seen by some of its supporters as (in lord Joffe's words): 'a first stage and possible the final stage, but there could be subsequent stages' and by its opponents as the first step onto a slippery slope.
Many of the people who have written to us have drawn parallels between the Bill and the Abortion Act of 1967. They have pointed to the similarity between the arguments advanced to support the latter... and those used to advance the present bill, and to the disparity between the intention of the Act's sponsors - that abortion would be an exceptional procedure - with the reality, in which at the last count there were over 180,000 abortions carried out annually in England and Wales. Their concern is that the legalisation of euthanasia, even with the strictest of safeguards, might have similar results. In his evidence to us, Lord Walton cited experience of the Abortion Act. 'I do not believe,' he said, that the Abortion Act has been significantly amended in relation to its provisions but those provisions have been widely ignored, leading virtually to abortion on demand'.
The essential concern under this heading is that some terminally ill people might feel under pressure, if the option of assisted suicide or voluntary euthanasia were to be available in law, to avail themselves of it in the interests of others (particularly family members) rather than themselves positively wishing to die in this way. Maura Buchanan of the Royal College of Nursing suggested that some terminally ill patients 'might have to use the Bill when the cost of nursing home care started to eat away the family's inheritance. It would be easy to succumb to pressure and feel you had to give up or feel that you were a burden, when the family in today's world do not sit at home looking after mother or elderly relatives, because everybody has to work to keep the mortgage going'.
Baroness Greengross took the view 'that the whole question of being a burden to society as a whole is something that is widespread amongst older people, especially in Northern Europe and North America. It is part of our culture, where a lot of older people say they do not want to be a burden on their families. However loving, and we must accept that as part of our culture'. Dr Jim Gilbert, a medical director of palliative care in Devon, raised a related concern - that some patients, whilst not opting for ending their lives, would feel themselves presented, if the law were to be changed, with an ongoing choice to be made.
Nonetheless, this is the concern which has been raised with us most frequently in the context of the slippery slope both by witnesses giving oral evidence and in very large numbers of letters and emails from members of the public. As we will see later in this chapter, it is a concern which is felt particularly strongly in relation to potentially vulnerable groups of people, such as the disabled and the elderly.
Though this is a term coined by one of our witnesses, it refers to an issue highlighted by others. The essence of the concern here is that, if assisted suicide and voluntary euthanasia should be legalised and if implementation of the law were to be carried out within the health care system, these procedures will of necessity become a therapeutic option: that over time there will be drift from regarding the death of a patient as an unavoidable necessity to regarding it as a morally acceptable form of therapy: that pressure will grow as a result for euthanasia to be applied more widely - for example, to incompetent people or minors - as a morally acceptable form of medical therapy which is considered to be in the patient's best interests...
Doctor - Patient Relationship
The concern that has been expressed on this score needs to be looked at from two standpoints - that of the patient and that of the doctor. On the one side, it has been suggested that the legalisation of medical assistance for suicide and euthanasia as could introduce a sense of distrust of doctors on the part of patients. On the other side, it is clear that many doctors are concerned that the introduction of assisted suicide and voluntary euthanasia as medical procedures could not only undermine the patient's trust in them but also run counter to the ethics of their profession.
...The BMA's view however was that legalising 'assisted suicide would affect some patient's ability to trust doctors and to trust medical advice'. And Dr Wilks also spoke of the importance, in the wake of recent adverse publicity for the medical profession, of maintaining the public`s trust in its doctors. 'I have a concern,' he said 'that re-defining the role of the doctor in the way that this Bill would do might pose some threat to that trust.' The majority of the letters that we have received from doctors express serious reservations about the impact of the Bill on both their relationship with their patients and the ethics of their profession. It is important to consider nurse/patient relationships, which the RCN felt could be jeopardised by the Bill (Written evidence, Paragraph 4.2).
...Dr Randall felt it would be better, 'if society wants assisted suicide, to take doctors out of it... You would not have this problem of elderly vulnerable people worrying about what would happen to them when they were in care'.
On the other hand, Dr Nathanson commented; 'What doctors find it impossible to consider is who would want to provide that service. They find it almost impossible to conceive who would want to spend their lives administering lethal injections. Whether such a service could ever be set up, and who would be the people who took part in it, raises very serious questions.' Dr Wilks cautioned that, 'the establishment of a separate service is a kind of signal that there is a different group of patients who do not deserve the same kind of overall assessment and communication and discussion about options, and they can go off to the euthanasia service instead'.
We were also given the results of a survey carried out by the Association for Palliative (APM). We were told that in the APM survey of its members, which attracted 84% response rate, 72% percent of respondents had said that they would not be prepared to participate in a process of patient assessment which formed part of an application for assisted suicide or voluntary euthanasia.
The evidence which we have taken from medical practitioners suggests that the prognosis of a terminal illness is far from being an exact science. 'It is possible,' we were told by the Royal College of General Practitioners, 'to make reasonable accurate prognoses of death within minutes, hours or a few days. When this stretches to months, then the scope for error can extend into years.' Professor John Saunders, also speaking for the Royal College of General Practitioners, said that 'prognosticating may be better when someone is within the last two or three weeks of their life. I have to say that , when they are six or eight months away from it, it is actually pretty desperately hopeless as an accurate factor.' The Royal College of Pathologists drew attention to 'a 30% error rate in the medically certificated cause of death', with 'significant errors in about 5% of cases'...
We put these issues to specialists in palliative care and neurological diseases. In written evidence the Association for Palliative Medicine had observed that 'defining the terminal phase is often much more difficult than people imagine, particularly in patients with non malignant disease such as cardiac or respiratory failure.' Asked to enlarge on this Dr David Jeffrey said, 'A simple bit of practical evidence is one of making benefit forms that are filled in for patients assigned to the doctor thinking that the patient has six months to live. I would not like to count how many of these forms I have signed in my life for patients still living after a year, eighteen months or even longer...'
An application under this Bill must be competent, which is defined as 'having the capacity to make an informed decision'. It seems to us that such capacity encompasses two capabilities - the ability to think clearly and come to a reasoned decision; the ability to form a judgement which is unclouded by transient and treatable psychological conditions. The former is, we would say, the easier to asses - in that the attending physician ought ot be able to spot the applicant who is non compus mentis or who is not in full control of his or her thought processes. But it is entirely possible for someone with this level of competence to have his or her judgement impaired by depression or despair and to reach decisions which, given time and adaptation to circumstances of terminal illnesses, he or she might well reverse.
...Mrs Christine Kalus, a clinical psychologist giving evidence of the British Psychological Society, referred to people 'who have episodes of reactive depression as a result of the diagnosis of life-limiting disease. Estimates vary, but within the population of cancer patients this is thought to be in the region of 25-40% at the time of diagnosis. And similar at other times on the cancer journey - eg on confirmation of metastatic disease.'
Another aspect of the problem of competence was exposed by witnesses from the Association of British Neurologists. Professor Christopher Kennard told us that 'with a number of the neurological conditions there is a whole issue of cognitive impairment as for example, there are patients who to the lay public appear relatively normal but could have severe cognitive impairments and therefore would be unable to give informed decisions in an area such as this.'
...Mrs Christine Kalus, for the British Psychological Society, told us that, 'Over the years my colleagues and I have rarely encountered people who want to end their life, although many express the wish their suffering was over. Thus, once appropriate symptom control has been achieved in so far as that is possible , people are able to regain some semblance of quality of life. However, it is also important to note that, in our combined experience, there have been very few people, probably less than ten, where there was no evidence of clinical depression or anxiety, their mental capacity being apparently intact, who had an express wish to die and would have welcomed assisted dying had it been available to them.'