Comment: BMJ blog misinformation about end of life decision-making in Belgium, the Netherlands and the UK

In a recent blog post, Tony Delamothe, a Deputy Editor of the BMJ, reporting on a speech made on assisted dying by Lord Harries, the former Bishop of Oxford, stated that:

in Belgium apparently anyone over 18 can request it [assisted dying], regardless of underlying condition

In Belgium, the “patient [must be] in a medically futile condition of constant and unbearable physical or mental suffering that cannot be alleviated, resulting from a serious and incurable disorder caused by illness or accident” (Belgium, Act on Euthanasia of May 28 2002 (2003) 10 Eur. J. Health L. 329, s.3§1).

Further, Delamothe, and presumably also Lord Harries whose views he is recounting, confuses non-voluntary euthanasia with involuntary euthanasia when discussing the Dutch experience. Euthanasia is voluntary when it is ‘carried out at the request of the person killed.’  Euthanasia is ‘involuntary when the person killed is capable of consenting to her own death, but does not do so, either because she is not asked, or because she is asked and chooses to go on living.’  Non-voluntary euthanasia occurs when the individual is incompetent to consent to or refuse euthanasia and has made no prior decision. (Peter Singer, Practical Ethics (2nd ed.) (Cambridge: Cambridge Univ. Press, 1993) 176, 179). Dutch evidence of ‘termination of life without request’ almost entirely represents non-voluntary rather than involuntary euthanasia:

In the past, incidental cases had been found in which there had been no discussion with a competent patient, but in 2001 no such cases were found ([there is] no data for 2005). (Griffiths, Weyers and Adams, Euthanasia and the Law in Europe (Hart, 2008) 181-182).

The number of reported cases of termination of life without request in the Netherlands in 2005 was 24. (The 2005 reporting rate was 80%.) These 24 cases are described as follows:

When life was ended without the explicit request of the patient, there had been discussion about the act or a previous wish of the patient for the act in 60.0% of patients, as compared with 26.5% in 2001. In 2005, the ending of life was not discussed with patients because they were unconscious (10.4%) or incompetent owing to young age (14.4%) or because of other factors (15.3%). Of all cases of the ending of life in 2005 without an explicit request by the patient, 80.9% had been discussed with relatives. In 65.3% of cases, the physician had discussed the decision with one or more colleagues. (van der Heide A, Onwuteaka-Philipsen, Rurup ML, et al. End-of-life practices in The Netherlands under the Euthanasia Act. N Engl J Med (2007) 356:1957).

Finally, the post simply accepts an outdated account of the role of the doctrine of double effect in palliative care. Describing Lord Harries’ lecture, Delamothe writes that “his church accepts the principle of “double effect” – ie it’s legitimate to give patients large doses of morphine to relieve their suffering, even if this hastens their death. (Intentions, not outcome, are apparently crucial here.)” Later, he recounts Lord Harries’ asking “does the public really understand what palliative care can offer? Do they know that it’s legitimate for doctors to give them large doses of morphine to relieve their suffering, and that perhaps a third of (?cancer) deaths are hastened in this way?” Delamothe fails to point out that the stretching of the criminal law to accommodate the doctrine of double effect is no longer necessary, and may, although well-intentioned, have unintended side effects. In a review of the medical literature worldwide, Sykes and Thorns conclude that:

The doctrine of double effect is used as an ethical justification for the specific risk of foreseeable life shortening as a result of a medical treatment. However, we suggest that there is no evidence that the use of opioids or sedatives in palliative care requires the doctrine of double effect as a defence. We have specifically examined the role of this doctrine in relation to symptom control and found that in 238 patients in a specialist palliative-care unit (89% receiving strong opioids and 48% receiving sedation) there was no evidence that that the doctrine needed to be invoked in relation to any morphine therapy. . . . Thus, although the doctrine is a valid ethical device, it is, for the most part, irrelevant to symptom control at the end of life. To exaggerate its involvement perpetuates a myth that satisfactory symptom control at the end of life is inevitably associated with hastening death. The result can be a reluctance to use medication to secure comfort and a failure to provide adequate relief to a very vulnerable group of patients. (Sykes Nigel; Thorns Andrew. The use of opioids and sedatives at the end of life. The Lancet Oncology 2003;4(5):312-8, 317.)

In addition, the most recent UK evidence is that in 2007-2008, 22.5% of all cancer deaths and 17.1% of all deaths involved an end of life decision to alleviate symptoms with estimated ‘double effect’ (Clive Seale. End-of-life decisions in the UK involving medical practitioners. Palliative Medicine, Vol. 23, No. 3, 198-204 (2009).).

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