The myth of the medical executioner

Why the elderly have nothing to fear from v.e.

Colin Gavaghan


Every so often, a VESS member raises the point that those in the right-to-die movement spend too much time going over the same old ground, and that we would do better to attempt to understand the arguments and concerns of our opponents. This idea has much to commend it - if nothing else, our prospects of winning an argument are considerably improved if we understand where the other person is coming from.


The problem with attempting to empathise with the anti-euthanasia lobby, to see things from their perspective, lies in the fact that so many of their arguments are, to be perfectly frank, rather ridiculous. Suggestions that ‘killing is always wrong’ ring hollow when a doctor is already free to hurry along a patient’s death, provided he shelters behind the tenuous active/passive distinction, or the even more dubious doctrine of ‘double effect.’ And the ‘right to life’ argument loses some of its intuitive appeal when it becomes clear that what is being advocated is closer to a ‘duty to live’, whether you want to or not.


There is one argument, however, regularly advanced by v.e. opponents, which is not so readily dismissed. This claims that, while ostensibly expanding choice, the legalisation of voluntary euthanasia will in fact result in the killing of people - the elderly in particular - who do not really want to die. In particular, we are told that we should be fearful of how the medical profession will use this newly vested power over life and death, a fear expressed in Capron’s now famous passage:


"I never want to have to wonder whether the physician coming into my crubs) of a healer, concerned only to relieve my pain and restore me to health, or the black hood of the executioner." (A.M. Capron, "Legal and Ethical Problems in Decisions for Death", 1986, 14 Law Med Hlth Care 141.)


For those of us who believe in individual choice at the end of life, the possibility that the end result of our efforts would be to pressurise anyone into ending a life they still considered worth living is obviously quite abhorrent. If there were shown to be substance to these alleged dangers a great many of us may have to revise our opinions about the merits of legalising v.e. But has any such substance been demonstrated? Short of repeating them with great frequency and considerable volume, has the anti-v.e. lobby actually put forward any evidence to support their colourful claims? Or is it the case that, when the powerful imagery and emotive rhetoric are stripped away, there is once again nothing left of the anti-choice case?


Unscrupulous doctors?


The threat that doctors will abuse legalised v.e. to end the lives of some patients who are quite happy to go on living is a much used weapon in the armoury of the anti-v.e. lobby. After all, they contend, in an environment where the medical profession (particularly those working within the NHS) frequently find themselves underfunded and understaffed, we should expect some medics to see the ending of elderly lives as a tempting solution. The elderly, after all, consume a disproportionate percentage of NHS resources, and may be seen by others to have little worth living for.


According to the strong version of the claim, legalised v.e. would result in physicians actually killing those who wish to go on living. A brief examination of the merits of such a claim, however, show it to be fanciful in the extreme. Such an act, which even the most ardent supporter of v.e. would regard as murder, would not only end the doctor’s career, but would see him facing life in prison. Even assuming that there are doctors willing to act in such blatant contravention of professional ethics and societal morals, they would presumably require a stronger incentive in order to undertake such a risk than the prospect of saving the NHS a few thousand pounds. It is also worth bearing in mind that a suitably motivated doctor, supremely confident of evading detection, would not require voluntary euthanasia to be legalised before going about his murderous work.


The notion that they may seek to circumvent the requirement for patient consent in less direct ways, however, has a good deal more support. The substance of this version of the argument is that some of those elderly persons who request aid in dying will be doing so not because they feel their lives to no longer be worth living, but because of pressures - real or perceived - to avail themselves of this option.


That doctors can influence the treatment decisions of their patients by the manner in which they present information is widely accepted. Persuading competent, happy adults that they would be better off dead may seem like a nigh on impossible task - there are, one may assume, few with the persuasive powers of Jim Jones or David Koresh within the British medical profession, and the average British doctor may find the self-preservation instinct a more problematic obstacle. For those dealing with the elderly, though, the situation may be different. Patients in the early stages of dementia may still remain competent to give consent, but competence is a sliding scale, and the capacities upon which it is dependent may be fading. The possibility must therefore arise that confused and frightened patients could find themselves agreeing to v.e. without properly appreciating what they are agreeing to.


For those charged with framing any future v.e. legislation, a major task will of course be to build in checks and safeguards to prevent any such abuse. But is it really the case that doctors would want to act like this anyway? Are our GPs really executioners waiting to happen?


The evidence from the Netherlands, until very recently the only country in the world where v.e. can be practised without resulting in criminal charges, suggests that this danger may, to say the least, be somewhat exaggerated. Both Vander Wal and Remmelink found that euthanasia as a cause of death is most common between the ages of 35 and 70, particularly in those who suddenly developed cancer - very few cases seem to involve those in their 80s or older. Among nursing home residents, euthanasia is especially rare, accounting for only one death out of every 800. Of the 52,000 patients in Dutch nursing homes, there are only 300 requests for euthanasia, and only 25 actual acts, each year.


All of this would seem to suggest that the medical profession are not likely to use the ‘god-like’ powers which v.e. would give them to undertake some frenzied killing spree. On the contrary, if the experience of the Netherlands is anything to go by - and after all, where else can we look for such evidence? - doctors have been extremely reluctant to exercise those powers unless entirely satisfied that the patient genuinely wishes to die.


What of the medical profession in Britain? We may have no experience with legalised v.e., but the views and actions of doctors tell their own story. In particular, while our medical profession are broadly accepting of withdrawing life-sustaining treatment in ‘futile’ cases, and are coming to accept physician assisted suicide in ever greater numbers, they remain for the most part opposed to the active termination of life. Sheltering behind the contrived concepts of ‘double effect’ and the ‘active/passive’ distinction may seem logically unsustainable, even hypocritical. Yet it is intriguing, and perhaps a little comforting, to note that were v.e. to be allowed our major problem may lie with trying to persuade our doctors to carry it out, rather than with trying to curb their enthusiasm for the practice.


This is not to say that the medical profession should be trusted implicitly. Examples of paternalism still abound, and too many patients still have to fight to have their wishes respected. But it seems highly unlikely that doctors would interpret legalisation as anything like a license to kill.


Do the elderly fear legalised v.e.?


Whether or not the legalisation of v.e. would pose a real risk to the elderly, there remains a further question. If legalisation had the effect of causing unease, or even fear, among the elderly, does this not provide some reason for concern about legalisation?


In a recent column, Melanie Phillips, tireless campaigner against individual choice and freedom, gave voice to just such a fear. (The Observer, 28 September 1997). Certainly, if such distress was shown to be present among the elderly in significant numbers, this would weigh heavily on the anti-legalisation side of he scales. But has such widespread fear actually been demonstrated? Or is it once again the case that the scaremongering rhetoric of the anti-choice lobby originates entirely in their own imaginations?


According to one report - a report to which our opponents make frequent reference - as many as 95% of Dutch nursing home inhabitants are afraid of being killed against their will. This sounds fairly conclusive - until one hears the evidence of Dr. Paul Van Der Maas, lead author of the Remmelink Report. According to Van Der Maas, rumours of a nation of terrified pensioners originate from a single newspaper report, dealing with a survey done by the Dutch Physicians’ League. It may not come as a huge surprise to learn that the Dutch Physicians’ League is in fact a ‘pro-life’ group. Having asked to see their data, Van der Maas "found that it was a survey of a selected group of their own members and that two per cent had responded that they were afraid, not 60 per cent or 90 per cent." He regarded it as "a very unscientific study."


Hardly a very reliable piece of research upon which to build such an important strand of one’s argument! Insofar as it tells us anything at all, the conclusion is that Dutch retirement home residents are for the most part not afraid of their doctors at all. The extent to which the prospect of legalised v.e. would instill fear in the elderly does not appear to have been investigated as horoughly as it perhaps should. But the evidence which has come to light suggests that if such fear exists at all, it is not particularly widespread. Certainly, the fact that VESS counts so many retired persons among its membership certainly gives room for scepticism! A poll of retired persons by ‘Yours’ magazine in 1994 adds support to this belief. As well as overwhelming supporting legalisation of v.e., only 29% agreed that "legalising euthanasia would allow the unscrupulous to end a patient’s life without consent."


Indeed, numerous pieces of research have demonstrated that older people, for the most part, worry more about the circumstances of their dying than about the prospect of death itself. Their fear is not of doctors assuming the role of executioners, but of torturers, applying all the instruments and devices of modern medicine to drag out their patients’ suffering for as long as possible.


Which is not to say that the 29% who did express concern at this prospect should be discounted; the role of the right to die movement must be to reassure those who harbour reservations about v.e., just as surely as it is to attack those who oppose it outright. Those fears and concerns apparent in the ‘Yours’ poll are quite understandable, given the efforts of the anti-v.e. movement to conjure up nightmare images of a medical profession embarking on a wholesale cull of the aged. Fortunately, such horror stories appear to have little, if any, basis in reality. The medical profession may have a less than unblemished record of respecting individual autonomy, but there is no reason to suspect that they are the potentially murderous ‘bogie-men’ of pro-life legend. Rather than the hooded figure of the executioner, it seems that our opponents are in reality trying to frighten us with no more than fairytales.