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The final autonomy
976
The final autonomy SIR,-If the British Medical Association were to look across the North Sea, as your editorial of Sept 26 recommends, they should not be given cause for abandoning what you call "their unsympathetic public line" on euthanasia. Dutch practice, as is evident from the Remmelink report’ and from independent research,2-4 is a salutary warning against the law accommodating the practice of euthanasia by doctors. Euthanasia, including nonvoluntary euthanasia, is now out of control in the Netherlands. It is true that public statements from some leading practitioners may give an impression of muddled counsel on the part of the profession in the UK. But sometimes apparent muddle results from special pleading in an effort to rationalise and defend the behaviour of colleagues when no coherent defence can be provided consistent with a principled opposition to the legalisation of euthanasia. Contrary to what you suggest, there is a clear intellectual case for opposing any legal exception to the norm that doctors should never seek intentionally to bring about the death of their patients. Pain or any other form of suffering should not be thought to so nullify the worth of a patient’s life that it can be deemed beneficial to kill that patient. The euthanasiast judgment that death will be a benefit to a patient depends on believing that the patient’s life is no longer worthwhile. To accept that doctors may kill people on that basis is to accept that the practice of medicine need not be governed by respect for the basic dignity of every patient, recognition of which is incompatible with holding a patient’s life to be not worthwhile. However impaired a person’s subjective sense of dignity and worth may be, doctors need to hold fast to recognition of the objective dignity of every human life committed to their care. Certain forms of treatment may cease to be worthwhile or become an excessive burden and for those reasons be terminated, but the lives of patients are not to be terminated because they are deemed no longer worthwhile or an excessive burden. Linacre Centre, 60 Grove End Road, London NW8 9NH, UK 1.
LUKE GORMALLY
Gunning KF. Euthanasia. Lancet 1991; 338: 1010 Some reflections on euthanasia in the Netherlands. In: Gorrnally L, ed. The dependent elderly: autonomy, justice and quality of care. Cambridge: Cambridge University Press, 1992: 70-100. Keown J. The law and practice of euthanasia in the Netherlands. Law Quart Rev 1992;
2 Keown J.
3.
108: 51-78. 4. Gomez CF. Regulating death: euthanasia and the Free Press, 1991.
case
of the Netherlands. New York:
SiR,—In managing patients with little or no prospect of recovery physicians face a dilemma: to institute (and continue) life-sustaining measures or not.1-3 Artificial feeding, which caters to the basic human need for hydration and nutrition, is one such measure: early and energetic intervention may improve survival yet prolong the suffering of the patient and relatives.4 Our study on physicians’ practices and attitudes towards artificial feeding of elderly patients with major stroke may inform the debate between supporters of euthanasia and pro-life campaigners. RESPONSES OF PHYSICIANS TO QUESTIONS ABOUT NASOGASTRIC TUBE FEEDING OF STROKE PATIENTS
Consultants and senior registrars in the specialties of general medicine and in medicine for the elderly, likely to be responsible for management of elderly patients with stroke, in the Northern and Oxford regions were invited to take part in a postal questionnaire survey. The local ethics committees approved the study. The response rate was 54% (119/219). For the first 48 hours after the onset of a dense stroke in an 80-year-old patient which left her semicomatose and unable to swallow, 68 (57%) physicians would offer artifical feeding, mainly intravenous fluids. 59 physicians (50%) would continue artifical feeding, usually via nasogastric feeding tube, beyond 4 weeks. Several factors influenced decisions about artifical feeding (table). Our study confirms that passive euthanasia, by withholding artifical feeding in elderly patients with a dense stroke, is widely prevalent. In following such a course of action many physicians did not seek guidance from patients’ relatives, and a significant proportion might thus be liable to legal action in the current climate of increasing litigation. Our findings reinforce a need to resolve the dilemma facing physicians. Living wills and advance directives may help but guidelines, drawn up in conjunction with ethicists and lawyers, may be better. Department of Medicine for the Elderly, Sunderland District General Hospital, Sunderland SR4 7TP, UK
DINESH CHADHA SUJIT BASU
District Headquarters, Poole Hospital, Middlesbrough
RAJAN MADHOK
PP, Bayer AJ, Tomlinson A, Pathy MSJ. Attitudes of hospital doctors in Wales of intravenous fluids and antibiotics in the terminally ill. Postgrad Med J 1989; 65: 650-52. 2. Micetich KC, Steinecker PH, Thomasma DC. Are intravenous fluids morally required for a dying patient? Arch Intern Med 1983; 143: 975-78. 3. Quill TE. Utilization of nasogastric feeding tubes in a group of chronically ill, elderly patients in a community hospital. Arch Intern Med 1989; 149: 1937-41. 4. Lo B, Dombrand L. Understanding the benefits and burdens of tube feeding. Arch Intern Med 1989; 149: 1925-26. 1. Marin
to use
editorial on the Cox case recommends that the law leaves doctors compassionately to help terminally ill patients from this mortal coil. Perhaps it is up to the medical profession to help the lawyers avoid entering this troubled area by unfailingly applying the principle of double intention. If physicians use opioids to relieve suffering and as a consequence accelerate the dying process they will be immune from prosecution. The practical consequence of this approach is to continue to increase the dose of opioids until either suffering is relieved or death occurs. Dr Cox’s first error was to use potassium chloride, a substance with no analgesic properties. His second was to record his actions. One would have to be naive to believe that unflinching honesty will be universally applauded; a certain amount of hypocrisy is necessary for the smooth running of society. The next error was the jury’s in finding Dr Cox guilty. British juries have a fine tradition of bringing in not guilty verdicts if the law is foolish or inappropriate despite the accused’s obvious technical guilt. Again there was a lack of hypocrisy. Let us hope that the General Medical Council can avoid the temptation of being too legalistic and with a little compassion allow Dr Cox to resume his practice. Green
College,
SIMON J. ELLIS
Oxford, UK
Blood donation
Response rates *62% and t50% tChl-squared, NS=notsignihcant.
SIR,-Dr Rodell’s letter from the American Blood Resources Association (ABRA) (Sept 12, p 677) should not go without comment. The contribution of all blood and plasma donors is appreciated and should not be linked to the marketing interests of ABRA in promoting its plasma business. The published data relating to HCV-antibody testing of donors presented by Rodell needs to be set against those of Dawson et al,’ supported by information cited in the package insert of the Ortho HCV-ELISA test system.2 At the outset of hepatitis C virus antibody (HCV-Ab) screening, they found repeatedly reactive/confirmed positive tests in the plasma of 0-35 % and 0-6%, respectively, of volunteer unpaid blood donors and in 10% and 6-7%, respectively, of commercial paid plasma donors.
The final autonomy SIR,-If the British Medical Association were to look across the North Sea, as your editorial of Sept 26 recommends, they should not be given cause for abandoning what you call "their unsympathetic public line" on euthanasia. Dutch practice, as is evident from the Remmelink report’ and from independent research,2-4 is a salutary warning against the law accommodating the practice of euthanasia by doctors. Euthanasia, including nonvoluntary euthanasia, is now out of control in the Netherlands. It is true that public statements from some leading practitioners may give an impression of muddled counsel on the part of the profession in the UK. But sometimes apparent muddle results from special pleading in an effort to rationalise and defend the behaviour of colleagues when no coherent defence can be provided consistent with a principled opposition to the legalisation of euthanasia. Contrary to what you suggest, there is a clear intellectual case for opposing any legal exception to the norm that doctors should never seek intentionally to bring about the death of their patients. Pain or any other form of suffering should not be thought to so nullify the worth of a patient’s life that it can be deemed beneficial to kill that patient. The euthanasiast judgment that death will be a benefit to a patient depends on believing that the patient’s life is no longer worthwhile. To accept that doctors may kill people on that basis is to accept that the practice of medicine need not be governed by respect for the basic dignity of every patient, recognition of which is incompatible with holding a patient’s life to be not worthwhile. However impaired a person’s subjective sense of dignity and worth may be, doctors need to hold fast to recognition of the objective dignity of every human life committed to their care. Certain forms of treatment may cease to be worthwhile or become an excessive burden and for those reasons be terminated, but the lives of patients are not to be terminated because they are deemed no longer worthwhile or an excessive burden. Linacre Centre, 60 Grove End Road, London NW8 9NH, UK 1.
LUKE GORMALLY
Gunning KF. Euthanasia. Lancet 1991; 338: 1010 Some reflections on euthanasia in the Netherlands. In: Gorrnally L, ed. The dependent elderly: autonomy, justice and quality of care. Cambridge: Cambridge University Press, 1992: 70-100. Keown J. The law and practice of euthanasia in the Netherlands. Law Quart Rev 1992;
2 Keown J.
3.
108: 51-78. 4. Gomez CF. Regulating death: euthanasia and the Free Press, 1991.
case
of the Netherlands. New York:
SiR,—In managing patients with little or no prospect of recovery physicians face a dilemma: to institute (and continue) life-sustaining measures or not.1-3 Artificial feeding, which caters to the basic human need for hydration and nutrition, is one such measure: early and energetic intervention may improve survival yet prolong the suffering of the patient and relatives.4 Our study on physicians’ practices and attitudes towards artificial feeding of elderly patients with major stroke may inform the debate between supporters of euthanasia and pro-life campaigners. RESPONSES OF PHYSICIANS TO QUESTIONS ABOUT NASOGASTRIC TUBE FEEDING OF STROKE PATIENTS
Consultants and senior registrars in the specialties of general medicine and in medicine for the elderly, likely to be responsible for management of elderly patients with stroke, in the Northern and Oxford regions were invited to take part in a postal questionnaire survey. The local ethics committees approved the study. The response rate was 54% (119/219). For the first 48 hours after the onset of a dense stroke in an 80-year-old patient which left her semicomatose and unable to swallow, 68 (57%) physicians would offer artifical feeding, mainly intravenous fluids. 59 physicians (50%) would continue artifical feeding, usually via nasogastric feeding tube, beyond 4 weeks. Several factors influenced decisions about artifical feeding (table). Our study confirms that passive euthanasia, by withholding artifical feeding in elderly patients with a dense stroke, is widely prevalent. In following such a course of action many physicians did not seek guidance from patients’ relatives, and a significant proportion might thus be liable to legal action in the current climate of increasing litigation. Our findings reinforce a need to resolve the dilemma facing physicians. Living wills and advance directives may help but guidelines, drawn up in conjunction with ethicists and lawyers, may be better. Department of Medicine for the Elderly, Sunderland District General Hospital, Sunderland SR4 7TP, UK
DINESH CHADHA SUJIT BASU
District Headquarters, Poole Hospital, Middlesbrough
RAJAN MADHOK
PP, Bayer AJ, Tomlinson A, Pathy MSJ. Attitudes of hospital doctors in Wales of intravenous fluids and antibiotics in the terminally ill. Postgrad Med J 1989; 65: 650-52. 2. Micetich KC, Steinecker PH, Thomasma DC. Are intravenous fluids morally required for a dying patient? Arch Intern Med 1983; 143: 975-78. 3. Quill TE. Utilization of nasogastric feeding tubes in a group of chronically ill, elderly patients in a community hospital. Arch Intern Med 1989; 149: 1937-41. 4. Lo B, Dombrand L. Understanding the benefits and burdens of tube feeding. Arch Intern Med 1989; 149: 1925-26. 1. Marin
to use
editorial on the Cox case recommends that the law leaves doctors compassionately to help terminally ill patients from this mortal coil. Perhaps it is up to the medical profession to help the lawyers avoid entering this troubled area by unfailingly applying the principle of double intention. If physicians use opioids to relieve suffering and as a consequence accelerate the dying process they will be immune from prosecution. The practical consequence of this approach is to continue to increase the dose of opioids until either suffering is relieved or death occurs. Dr Cox’s first error was to use potassium chloride, a substance with no analgesic properties. His second was to record his actions. One would have to be naive to believe that unflinching honesty will be universally applauded; a certain amount of hypocrisy is necessary for the smooth running of society. The next error was the jury’s in finding Dr Cox guilty. British juries have a fine tradition of bringing in not guilty verdicts if the law is foolish or inappropriate despite the accused’s obvious technical guilt. Again there was a lack of hypocrisy. Let us hope that the General Medical Council can avoid the temptation of being too legalistic and with a little compassion allow Dr Cox to resume his practice. Green
College,
SIMON J. ELLIS
Oxford, UK
Blood donation
Response rates *62% and t50% tChl-squared, NS=notsignihcant.
SIR,-Dr Rodell’s letter from the American Blood Resources Association (ABRA) (Sept 12, p 677) should not go without comment. The contribution of all blood and plasma donors is appreciated and should not be linked to the marketing interests of ABRA in promoting its plasma business. The published data relating to HCV-antibody testing of donors presented by Rodell needs to be set against those of Dawson et al,’ supported by information cited in the package insert of the Ortho HCV-ELISA test system.2 At the outset of hepatitis C virus antibody (HCV-Ab) screening, they found repeatedly reactive/confirmed positive tests in the plasma of 0-35 % and 0-6%, respectively, of volunteer unpaid blood donors and in 10% and 6-7%, respectively, of commercial paid plasma donors.