Euthanasia and the law of unintended consequences. Speech given in Seoul on how Euthanasia becomes a deadly and dangerous contagion which threatens the safety of the vulnerable, compromises medics, gets driven by economics, deeply affects society and becomes a runaway train
It is a great pleasure to follow Professor Dongyiel Syn – and to be in Seoul again.
In exploring the question of euthanasia I will try to build on his remarks by discussing how a respect for the sanctity of every unique human life can be eclipsed – and circumstances are created in which the previously unimaginable and unthinkable becomes commonplace and routine – at every stage of our lives, from the moment life begins in the womb, to the moment it ends, from the womb to the tomb.
75 years ago In 1948 the Universal Declaration of Human Rights insisted in Article 3 that “Everyone has the right to life, liberty and security of person” while in 1950 the European Convention of Human Rights, stated in Article 2, that “Everyone’s right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which this penalty is provided by law.”
Nowhere in the ECHR’s 18 Articles or the 30 articles of the UDHR does it say there is a right to end the life of a baby in the womb; nowhere does it say that this is “a human right.”
Nowhere does it promote euthanasia as a human right.
Given all that had occurred in the preceding years, it would have been unthinkable to have done so.
Today’s worldwide epidemic of abortion and now euthanasia laws must be seen against that backdrop and in a contemporary context where care and kill are being used as interchangeables and where so-called safeguards are a self-deluding fiction.
The evidence is clear: euthanasia is being promoted and practised in the context of a complete disregard for the sanctity of life; but also in the context of the mass manufacture and destruction of human embryos, the deliberate and grotesque creation of animal human hybrid embryos; in the context of eugenic and industrial scale abortion, some of it coercive.
It is all of a piece.
Nietzsche, the nineteenth century philosopher, said that opposition to such “progress” was a preoccupation of Christianity which he accused of holding back mankind by prioritising the weak.
Under his ‘transvaluation of values’, what was seen as good would be evil, and vice versa.
In the future, killing the weak would become good, and the strong man who did the killing would be a public benefactor, a ‘super man’, above good and evil.
More than once, and with horrifying results, Nietzsche’s ideas have been put into practice.
But, yes, Nietzsche was right in one respect: there is a fundamental clash between those who value every human being – because we believe each person is made in the image and likeness of a Creator – and those who believe that we are answerable only to ourselves and that the strong must always prevail over the weak.
Today, in an echo of Nietzsche’s accusations, those who defend traditional prohibitions on euthanasia are sometimes caricatured as uncaring or somehow in favour of suffering and pain.
Such caricatures conveniently ignore the profound societal and ethical reasons why such changes in law should be resisted.
And as we evaluate these questions, we each have to search our consciences and decide where we stand.
It is simply not possible to allow euthanasia for a determined few without putting much larger numbers of others at risk – there wont be a little euthanasia. A change in the law becomes a conveyor belt ready to deliver euthanasia, like abortion, on an industrial scale.
It’s a slippery slope that ends in a quagmire.
I will argue that in society at large the legalising of euthanasia leads to a profoundly negative shift in attitude towards terminally ill and other vulnerable patients, particularly people with disabilities.
Also, there are also consequences for the practice of medicine when the commitment to care becomes a commitment to providing the option of killing.
Euthanasia, often dressed up as assisted dying or assisted suicide can end up being used for people who have psychological and social concerns.
Note too that often it is not necessarily patients but people controlling them who press for assisted suicide; that frequently there are significant problems with safeguards; that data is concealed; medical care is distorted; and that that a change in law divides the medical community.
There are financial dangers associated with it, too, and there are profound consequences for wider society – with assisted suicide and euthanasia potentially becoming the only choice for some patients.
And let me also squarely rebut the argument about pain and suffering that those in favour rely on so heavily. With proper palliative care, almost all pain can be alleviated.
None of us want to experience debilitating or challenging illnesses – and the loss of autonomy and dignity, the suffering and pain, which can accompany illness. How we respond to those challenges defines what in a previous generation would be called “a good death.”
This will have implications for the one who is dying, for their relatives and friends, for those who care for them and for society at large.
Take the example of Alzheimer’s. There are very few people who haven’t had a friend or a relative contract dementia. It is estimated that worldwide some 55 million people are affected by this unwelcome disease.
I remember being very moved by a Korean novel which explores the theme of loss of mind and the loss of a loved one.
Please Remember Mom (published in the UK asPlease Look After Mother), by the critically acclaimed South Korean author, Kyung-sook Shin, is the story of 69-year-old So-Nyo who is separated from her husband as they are jostled by the crowds at the Seoul subway.
As the doors of a departing train close between them and she is separated from her loved ones they begin a desperate search to find her.
When they ultimately come to terms with their loss it is only after they have had to consider the life of the woman, the mother, who had made so many loving sacrifices for them, the memories that she represented, and the identity which she had given to them and their lives. That is the way to come to terms with the loss of loved ones not be arranging a lethal injection.
Any of us who have had the sad experience of being with someone we love as they die – especially when they can’t remember who they, or you, are – knows how distressing this can be.
And anyone who has been with someone after they have received a diagnosis telling them that their life is coming to an end knows how traumatic that can be too.
But all of this points to the need for unconditional love and support not the implicit message that we would prefer that they were dead.
We need a society in which such care and treatment is the norm.
In the case of dementia – but it is true of other illness too – it is crucially important that we invest our time and resources to ensure that dementia patients receive proper care. Happily, huge strides are constantly being made in combating previously incurable diseases, and we must continue to search for cures as well as providing adequate resources for palliative care.
Dependence on others is natural at certain stages in life. At birth we were all dependent on others, and for that matter for a considerable time thereafter.
Neither our entry into this world or our departure from it are straightforward or trouble free.
Dying is part of living and that too may well make us dependent on others. We must try to be less fearful of this and question the mantra drummed into us that independence and autonomy are gods.
Dependence is not a cause for shame.
It should be a given attribute of a civilised society that a person will be cared for with compassion and not ignored or regarded as a burden.
Nelson Mandela expressed the principle in an African phrase about ubuntu that “a person is a person because of other people”- that the wider community has a responsibility to uphold the intrinsic value of another person – that our responsibilities are towards one another. The over exaggerated focus on ourselves, on rights rather than responsibilities, – on me rather than you – is at the heart of many of the ills in the world today.
Patient choice is clearly a good, but it is not the only good, and sometimes there is an overriding good – not least by the way in which law and the practice of medicine always demonstrate how society values human life – and in all circumstances.
The exercise of choice is always done in a context and invariably choices carry consequences – and not only for the person exercising the choice. To have a right to do a thing is not at all the same as to be right in doing it
A UK parliamentary committee spelt out how changes to the law must have regard to the impact on society. It said:
“Iindividual cases cannot reasonably establish the foundation of a policy which would have such serious and widespread repercussions… Dying is not only a personal or individual affair. The death of a person affects the lives of others, often in ways and to an extent which cannot be foreseen. We believe that the issue of euthanasia is one in which the interest of the individual cannot be separated from the interest of society as a whole”.
As The New York State Task Force on Life and the Law reported:
“The legalization of assisted suicide would itself send a message that suicide is a socially acceptable response to terminal or incurable disease. Some patients are likely to feel pressured to take this option, particularly those who feel obligated to relieve their loved ones of the burden of care. Those patients who do not want to commit suicide may feel obligated to justify their decision to continue living”.
There are obvious dangers for those whom Nietzsche would have regarded as “weak” – disabled people who were, after all, the very first to be eliminated in the Reich’s implementation of euthanasia as part of its eugenic cleansing of society.
My colleague, Baroness Jane Campbell, who has spinal muscular atrophy, is a Commissioner of the Equality and Human Rights Commission, and speaks in Parliament through an oxygen mask says this:
“Disabled peoples’ lives are invariably seen as less worthwhile than those of non-disabled people. Descriptions such as tragic, burdensome, and even desperate are routinely used without objection. Unless one is extraordinarily strong, this negativity impacts on the individual disabled person. If suicide were a legally and socially acceptable option, too many would succumb to this fate believing being ‘put out of misery’ to be expected of them……..Euthanasia is dangerous and threatening. I and many other severely disabled people will not perceive your support for it as an act of compassion, but one founded in fear and prejudice.”
Professor Stephen Hawking, the English theoretical physicist, mathematician, cosmologist, and author was at the time of his death in 2018, director of research at the Centre for Theoretical Cosmology at the University of Cambridge. He had motor neurone disease. He urged us tolook up to the stars, not down at our feet.
There could be no better rebuke to the constant negativity that disabled people are not ‘better off dead’, but that, paradoxically in what seems like weakness they can often teach and inspire the world with valuable lessons of hope and courage.
I am not offering a romanticised or unrealistic vision of how society should be.
I recognise that some relatives or carers can find looking after someone too onerous or too challenging. That’s where care must be organised.
When we fail to provide structural support a carer may feel worn down. In that state of mind, and not coping, and knowing that euthanasia is legal, a carer may deliberately or inadvertently make their feelings known to those for whom they are caring.
That can then make the cared for feel like an unnecessary burden; that they would be better off dead.
Some, for purely mercenary reasons, may want to see the life of the cared for person prematurely ended.
Changes in the law can be like music to their ears and can become an alibi for ending life🧿
While the majority of families are loving towards those of their members who are sick, some are not – let us not forget that elder abuse takes place within families. We have criminal laws, not because most people behave decently, but because a small number do not.
But the pressure to end your life, to see yourself as a burden may not just come from relatives who may gain but from public policy makers too.
The famous British philosopher Mary Warnock shockingly pointed us towards a future requirement not to be a burden on our loved ones or society. So the right to die becomes an obligation to die:
“If you’re demented, you’re wasting people’s lives – your family’s lives – and you’re wasting the resources of the NHS”.
in this thinking you become merely an economic statistic.
Death becomes a form of therapy.
Lady Warnock also said: “Pensioners in mental decline are wasting people’s lives because of the care they require and should be allowed to opt for euthanasia even if they are not in pain.”
What does this say about the mental competence of those who will apparently make free decisions? More strikingly, what does it tell us about the values of a society where becoming an economic burden will determine your right to treatment, compassion, or care?
In a letter to the British Medical Journal entitled How to really save money in the NHS”, policy makers argued that assisted suicide and euthanasia “would allow health expenditure to be substantially contained.”
Our laws have traditionally protected vulnerable people from such pressures but have protected the vast majority too – who, when the homicide law is relaxed to accommodate euthanasia, leaves people open to pressure from those who see killing, rather than caring, as the compassionate option.
Proponents of euthanasia will tell you that theirs is an act of mercy, that they did it for the person whose mind had been shattered, or who had been told they have a terminal illness.
But we must ask ourselves whether despatching someone with a lethal injection instead of giving them the best possible love and care and ultimately a good death are valid or licit alternatives
Our own experiences can sometimes cloud our judgement – especially when there has been a failure to provide proper care, or the response has been inadequate.
Individual stories can come to dominate the debate.
It is worth saying that if we have been fortunate enough to be with a loved one when they leave this world knowing how much they are loved and valued, that experience should also be weighed.
With his four brothers my father served in the Armed Forces in the Second World War. One lost his life. They had been particularly close, and his brother’s death had left a heart-breaking gap in my father’s life. It had left him angry with God. At the end of his life my father had a near death experience where he told me he had see his brother and he was “alright.” Make of that what you will but my father left this world at peace. A lethal injection to have saved him the suffering of the last part of his life would have denied him that.
There were around 600,000 deaths without euthanasia in England and Wales last year. A tiny number of hard cases make it into newspaper headlines.
Hard cases invariably make bad laws. We should not so easily discount the vast numbers of people who die peacefully, knowing that they had been well cared for but that their time had come.
And what of the doctors and nurses who should always be defenders of life?
Don’t commission them to destroy life. It is not their job, and it compromises the age-old Hippocratic Oath to “first do no harm.”
Just like we must weigh the implications of changing the law by how it will affect the sick we must also weigh carefully how it will affect the health professional; how it can undermine the trust which must exist between a doctor and a patient.
Historically, the mandate of the health carer is crystal clear. They must always care and never set out to kill or to assist in killing. Assisted living and for that matter assisted dying is practised every day by good health care professionals.
They have no duty to keep someone alive who has no desire for officious treatment. There is no moral or ethical obligation to go on receiving burdensome treatment when it is doing no good. There is no moral or ethical obligation to prolong life at all costs and in the UK that principle is quite properly reflected in all medical ethical codes.
The principle is that a medical professional must assist with the relief of pain and the alleviation of suffering. But their motive must not be to kill the patient.
Deliberately eliminating the patient is not treatment.
The British Medical Association have said “the risks of significant harm to a large number of people are too great to accommodate the needs of very few” while
the British General Medical Council was in no doubt that:
“A change in the law to allow physician-assisted dying would have profound implications for the role and responsibilities of doctors and their relationships with patients. Acting with the primary intention to hasten a patient’s death would be difficult to reconcile with the medical ethical principles of beneficence and non-maleficence”
Where one cannot cure, society should provide care.
That is why many of the UK’s medical organisations have opposed changes to the law. Especially palliative care doctors.
In the UK 95% of Palliative Medicine Specialists are opposed to a change in the law. Are they all uncaring? Or do they believe there are radical alternatives to the defeatism represented by a lethal injection.
I passionately support the provision and proper resourcing of palliative and hospice care. And I am the first to admit that where such care is patchy or uncertain, that provision must urgently be strengthened and made comprehensively available.
It was an illustrious English woman, a devout Christian, Dame Cicely Saunders, whom I was fortunate to meet, who was the founder of the modern hospice movement in England.
Dame Cicely trained as a nurse, a medical social worker and finally as a physician. Involved from 1948 onwards with the care of patients with terminal illness, she founded St Christopher’s Hospice in 1967 as the first hospice linking expert pain and symptom control, compassionate care, teaching and clinical research.
St Christopher’s has been a pioneer in the field of palliative medicine, which is now established worldwide. Dame Cicely once said: “You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die”.
Let me end by reminding you what is set in motion when you change the law. I will principally refer to Holland and Canada.
My reluctance to sanction change has been greatly influenced by paper-thin so-called protections and safeguards and by what has happened in other jurisdictions.
Let’s give legislators the benefit of the doubt and assume that their belief in small scale euthanasia has been driven by the belief it can be controlled and contained. Let’s call it the Law of Unintended Consequences.
First, recall that in the UK, legislators said that abortion would only every be used in grave and extreme circumstances.
There have now been 10 million abortions – one every 2.5 minutes some, in the case of disability, right up to and even during birth. Nor, as experience elsewhere illustrates, will there only be “a little bit of euthanasia”.
In 2002 in the Netherlands a Euthanasia law was enacted. It defined euthanasia as the administering of lethal drugs by a physician with the explicit intention to end a patient’s life on the patient’s explicit request. Even before this law came into effect, the decriminalisation of euthanasia was subject to abuse in the Netherlands.
Year by year the number of deaths has increased exponentially and within ten years a quarter of the euthanasias were not even being reported and recorded.
It had become normative and routine.
An official report suggested that a quarter were being done without the patient’s consent. Then it was reported that at Gröningen Hospital doctors had killed twenty-two babies with spina bifida.
They had made their actions public so that the law might be further changed enabling it to apply from birth.
Then Holland announced the introduction of mobile units to kill people in their own homes. It was reported that
“Dutch mobile euthanasia units to make house calls”that a “new scheme called ‘Life End’ will respond to sick people whose own doctors have refused to help them end their lives at home.” The report continued: “The teams would be limited to one house visit a week to minimize the psychological burden on them” – that is to the people operating the mobile units, not the patients.
The Dutch said that 80% of people with dementia or mental illnesses were being ‘missed’ by the country’s euthanasia laws; and that the doctor’s clinical judgements had led to an unacceptable refusal to administer lethal drugs to their patients.
The mobile death units are targeted at “unmet need”including people with chronic depression, disabilities, Alzheimer’s, loneliness, and those whose request to be killed has been refused by their doctors. It was as if the Dutch had forgotten the last time mobile death squads were deployed in Europe.
In Holland and Belgium patients with dementia can be euthanised. What happened here to the principle of consent? Where’s the autonomy?
People with psychiatric disorders are also eligible, as in the case of the 29-year-old Aurelia Brouwers who was euthanised in 2018 at her own request because of her chronic depression.
One outspoken proponent of euthanasia in the Netherlands is Dr Bert Keizer. He says that like abortion it is good that an initially tightly drawn law on euthanasia has been extended. He wants it to go further:
“Looking ahead, there is no reason to believe that this process will stop in cases of incapacitated demential. What about the prisoner who has a life sentence and desperately longs for death?”
When you commence a journey it’s as well to have a map which gives some indication of what you might expect to find at your destination.
Where both physician-assisted suicide and euthanasia have been legalised, data from the Netherlands and Canada show that euthanasia rapidly becomes the practiced mode of ‘assisted’ death.
Since “assisted dying” was legalised in Canada in 2016 there too has been an exponential increase.
In its first year, 1,018 people died by medical assistance in dying. In 2021, that figure was 10,064 – an increase of 889%. Over these five years, the law has expanded to include people with non-terminal illnesses, and recent reports show requests being made and approved, on the basis of poverty and lack of disability support. Proposals are in place to allow for individuals to request MAiD on the basis of mental illness.
Meanwhile, palliative care provision remains inadequate.
Indeed, euthanasia erodes palliative care and hospice provision.
A recent report from Canada reported that a man was offered euthanasia within two weeks of seeking help. By contrast, it took a year to see a doctor to treat his treatable condition. Another, a veteran, sought help and was offered a lethal injection.
Participating doctors in Australia report that assisted dying fundamentally changes medical practice and is incompatible with palliative care.
Assisted dying is not an extension of palliative care.
Proponents call for control and choice, yet people need real choices, not taking an action driven by despair. They need care that meets their needs and empowers them to live well.
Wherever the boundaries are set, evidence from other jurisdictions shows that the boundaries are eroded, and criteria expanded, with concomitant escalation in numbers, most markedly seen in Canada. It becomes a runaway train. And policy makers try to disguise the realities.
The data collected in different jurisdictions varies widely, with gaps in data.
Oregon’s reports are, for instance , destroyed after one year, impeding retrospective audit.
However, in all jurisdictions there is only post-event reporting by a doctor. This lack of real-time monitoring of assessments means that evaluation of how they were conducted is impossible. Such doctor-only reporting carries risks of bias, short-cuts in assessment processes with undue influence by the clinician.
Experience in jurisdictions with euthanasia also underlines the uncertainty about diagnosis and prognosis.
Defining ‘terminal illness’ is fraught with error. A prognosis of six months life expectancy is notoriously inaccurate A House of Lords Select Committee heard that “It is possible to make reasonably 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” and “when someone is six or eight months away from death, it is actually pretty desperately hopeless as an accurate factor”-
A required ‘prognosis’ in law inevitably results in many people ending their lives very early in the mistaken belief that death is far closer than it is.
A guestimate of prognosis is not a safeguard.
Canada has removed their “reasonably foreseeable” death criterion because of the vague nature of prognostication.
The House of Lords Select Committee also heard that post-mortem evidence showed around 1 in 20 patients had died from a condition different to that recorded on the death certificate.
A fundamental problem with the campaign for ‘assisted dying’ and euthanasia is that it assumes the existence of a perfect world – a world in which all terminally ill patients know what they want without any trace of doubt or despair, in which all doctors have the skills and time to conduct thorough assessments and in which all relatives are what the media like to call ‘loved ones.
While many of those who champion the legalisation of assisted suicide do so, I am sure, with the best of motives, I believe it to be a profound mistake. Its advocates suggest it is a well-researched, well-established medical intervention.
This is simply not the case.
Let me end by summarising why we should resist the legalising of euthanasia.
We should oppose it because so called safeguards are vague and have elastic properties enabling their effortless extension.
We should oppose it because conscientious objections of medics are routinely compromised or ignored and their objection that providing lethal drugs against imprecise and unverifiable date is arrogantly disregarded.
We should resist legalising euthanasia because it means abandoning better laws that protect the vulnerable and take account of the fears of disabled and vulnerable people are set aside.
Instead of putting their energy into promoting bad laws, legislators, policy makers, and governments should work instead for world class palliative care and resources for health care that values assisted living rather than expediting death.
