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Mahes Visvalingam
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End of Life Issues in Britain

 

CONTENTS

Disclaimer
Political Background

Philosophical viewpoints and ethical positions
 End of Life Care Programme Initiatives

Philosophical viewpoints and ethical positions

introduction,  sanctity, utility, autonomy, uncertainty, mystery, My conclusion, Some Links

 

Paragraphs refer to http://www.parliament.the-stationery-office.co.uk/pa/ld200405/ldselect/ldasdy/86/8606.htm

Introduction Please read my Disclaimer. 

 

The Mental Capacity Act of 2005, which came into force in October 2007 in England and Wales, gives competent adults over the age of 18 the right to make an Advance Decision (also referred to as an Advance Directive) to refuse specific medical treatments.  This is made through what is effectively a living will, which is legally binding if found to be valid.  They are also able to assign Lasting Power of Attorney to those they trust, who can refuse treatment if it was in the patient's best interests.  This page goes over the main philosophical arguments for and against the legal right to shorten life through the refusal of treatment.  Assisted dying is still illegal but Lord Joffe has resolved to get his Bill to legalise it through Parliament (see Background: 3).

 

Euthanasia has been traditionally rejected on humanitarian and religious grounds on the sanctity of life principle.  It seems to me that the principle of utility and its derivative, namely consequentialism, which underpins many legal decisions in western countries underpins the pro-euthanasia arguments.  As noted in the background, some forms of euthanasia are now legal in some countries.  The advocates of euthanasia in UK have advanced arguments in favour of autonomy, which they argue should include the right of the individual to choose the circumstances of death.  The law only provides the legal framework; codes of practice and guides are needed for its enforcement given the numerous uncertainties which need to be addressed.   Some of these uncertainties have become nightmarish visions for vulnerable people approaching the end of life; they include fear of unbearable pain, of physical and psychological abuse by carers and of financial fraud by trusted attorneys.  Our experience of ourselves and of our environment is dominated by left-brain mental capacity - the same capacity which articulates the above cultural and rational arguments for and against euthanasia.  Much of the brain is under-utilised and remains a mystery.  Mystics believe that we experience our primal nature or divine self when left-brain dominance is thwarted by meditation, a change in outlook and penance.  This state of mind may also be induced by trauma, disease, dementia and other conditions which impede left-brain activity. 

Sanctity of life This viewpoint relates to cultural and social beliefs and conventions.  Although religious beliefs and moral codes may remain fixed (e.g. the Catholic stance on abortion), public opinion and rational debate may cause a change in the law.  This poses a dilemma for staff, whose faith condemns all forms of euthanasia and suicide.  The sanctity of life proponents hold that:
  1. Life is God given and euthanasia is immoral and should continue to be illegal.
  2. Some religions hold that suicide is sinful.  But, it is not illegal in UK.  Those in favour of passive euthanasia argue that refusal of life-sustaining treatment is more like a suicide attempt and that it is quite different from assisted dying, which causes death.
However, this raises some contradictions. 
  • Currently, there is a strong moral (deontological) obligation to prevent suicide and resuscitate failed suicides, especially in prisons (para 71).  The withdrawal of treatment (which can include artificial ventilation, nutrition and hydration) contradicts society's attempts to frustrate suicide.  Should autonomy (i.e. individual choice) override beneficence in some cases, e.g. for the terminally ill with unbearable suffering? 
  • This in turn then begs why the priority of autonomy should apply only to these cases, when other would-be suicides may also regard their situation as unbearable, e.g. prisoners and chronically disabled people.

Therefore, the withdrawal of life-sustaining treatment on non-clinical criteria poses contradictions and tensions in the present socio-cultural context, which is pro-life.  However, the sanctity of life principle has been challenged; Jeremy Bentham dismissed deontology as akin to popular morality based on subjective opinion.
Utility Jeremy Bentham proposed that the moral principle of utility (or utilitarianism) should guide the right act or policy.  This principle seeks to achieve "the greatest happiness of the greatest number", where the consequences for everyone affected by the action must be taken into account.  The principle of utility (now regarded as one version of the principle of consequentialism) gives precedence to consequences or outcomes.  So, in consequentialism 'the means justify the ends', in contrast to deontology which gives precedence to the moral principles (e.g. sanctity of life) and their constraints on actions (e.g. the taking of life).

 

It could be argued that 'mercy-killing' and passive euthanasia achieve the greatest good for the greatest number - it is good for the person requesting it (relieves suffering), good for the relatives (who can now move on), and the state (solves a lot of problems for the cash-strapped NHS with as yet inadequate provisions for palliative care); see http://www.bbc.co.uk/religion/ethics/euthanasia/infavour/infavour_4.shtml.  A recent survey of 300 GPS for the Pulse magazine  states that younger GPs were more supportive of assisted suicide than colleagues over 65 (see Daily Telegraph report 19/05/07).  Those who opt for and support euthanasia tend not to be religious.

However,  there are some problems.
  • Deontological theories assert that an act can maximize the good but still be wrong if it violates some deontological principle, such as a categorical imperative to sustain life.
  • Consequentialism is predicated on the assumption of altruistic, neutral observers who take well-informed actions.  However, it is difficult for all those involved to act as such ideal observers, who are expected to go out of their way to acquaint themselves of all the general issues and of the circumstances of the specific case.  It could be argued that motives other than the best interests of the patient can be implicated in policy decisions and decisions taken by those with powers of attorney.
  • It seems like euthanasia is focused on eliminating the bad rather than in maximising the good outcomes. 
  • While it is possible to take account of intended and foreseen consequences (e.g. the double effect of causing death through (mis)use of morphine-derivatives), it is not possible to take account of unintended and unforeseen consequences.  So, part of the debate focuses on identifying such uncertainty.  Also, like science, consequentialism tends to ignore unobservable and unknown outcomes, such as that discussed under mystery below. 
Autonomy This principle, which promotes the rights of individuals, is one of ethical egoism, where the outcomes for the individual is regarded as more important than any other consequence.
  1. Autonomy relates to "the ability to choose and the freedom to choose between competing conceptions of how to live" ... "When we are denied control at the end of our lives, we are denied autonomy" (para 41).
  2. Since suicide is not an offence, autonomy over the time and mode of one's death already exists.   It is therefore discriminatory to deny this right to those who lack the physical capacity to kill themselves (para 42) when the exercise of this right does not harm others (para 43).
  3. It is inconsistent to refuse people active assistance to end their lives when treatment can be withheld without the patient's consent a) when it is deemed futile and burdensome (para 48), or b) when it is not cost-effective, as in the case of expensive cancer drugs.
  4. The denial of voluntary euthanasia is inconsistent with the acceptance of mercy-killing as in the case of the "policeman's dilemma" (para 47).

While the above explanation of autonomy in statement 1 above is laudable, it is alas only a platitude.  Lord Joffe explained what he thought autonomy meant with reference to the option of palliative care (see http://www.parliament.the-stationery-office.co.uk/pa/ld200405/ldselect/ldasdy/86/8605.htm#a6, para 27).  "All we can say is that, if the patient wants to have palliative care, he should ask for it and they should try to arrange it; but, if they do not or it is not possible, then the patient must make up his mind (My question - to choose euthanasia?). That is what autonomy is about. It is about choosing between the options available to you rather than the ones you would like to have".  Indeed, in the Leslie Burke case, the European Court of Human Rights ruled that artificial nutrition and hydration (ANH, which is still classed as medical treatment) was not available as an option on the grounds that the provision of treatments should be at the doctor's discretion ( Political Background: 4.2).  If ANH is at the doctor's discretion and is not an option that a patient can request in advance, why should medical intervention to assist dying be an available option? 

 

The current asymmetry in the law seems incongruent.  There appears to be different interpretations of the principle of autonomy when it comes to assisted dying, on the one hand, and assisted living (ANH and palliative care) on the other.  See also Political Background: para 6).  If patients request a treatment (eg surgery) the doctor need not agree to it if the risks are too great - so doctors ask why the request for even withholding of treatment is legally binding on them.  The argument of autonomous decision-making renders euthanasia into a social rather than a medical decision, which should not involve the doctors, since it compromises their function (as noted by Dr Gill Turner, representing the British Geriatrics Society, and others).  Many ask whether doctors should be responsible for administering passive euthanasia when their mission is to save and improve the quality of lives.  They suggest that it might be more appropriate for patients wanting passive euthanasia to seek the services of organisations set up for this purpose, such as EXIT and DIGNITAS in Switzerland (see para 198).

 

Others argue that autonomy should be limited and should only apply when:

  1. the outcomes are good and when one acts in one's best interest as traditionally understood, e.g. preserving life (para 44). 
  2. when the exercise of autonomy does not impact negatively on others.  This is why doctors, who make the ultimate decisions regarding treatment, may not administer antibiotics given the risk of promoting drug-resistant viruses (para 45).  Patient autonomy raises problems since :
    • it impinges on doctors' autonomy to choose between the patient's request and medical ethics (para 49 & 50).  When treatment is withdrawn, nature is left to take its course and some patients make a recovery, i.e. the outcome is uncertain.  If death follows, it is due to the person's medical condition (para 51).  This is radically different to causing death.  So, there is no contradiction as proposed in para 48 (points 2 & 3 above). 
    • it changes the message that the Law sends out, e.g. a) it puts pressure on other vulnerable and elderly people in similar situations to follow the current expectations; b) it has led to calls to extend euthanasia into other related areas as in Netherlands (para 92 & 93); c) it legitimises the growth of euthanasia services, as in Switzerland, which could seek to attract paying suicide tourists.

With respect to mercy-killing and the policeman's dilemma (statement 4 above), the law at present says — "if anyone should take upon him or herself the responsibility for ending someone else's life in order to prevent suffering, he or she must let the courts examine all the facts of the case and reach a judgement on guilt or innocence and on whether, and if so to what extent, the law should impose punishment" (para 68).  The European Court of Human Rights (2002) rejected Mrs Dianne Pretty's appeal to exempt her husband from prosecution under the 1961 Suicide Act for assisting her to commit suicide.  If Mr Pretty has assisted the death of his wife he would have had to do so with full knowledge of the consequences of mercy-killing. 

Uncertainty Most judgements and predictions are probabilistic.  It is therefore necessary to be mindful of the uncertainties when making and acting on Advance Decisions. 

 

The Mental Capacity Act of 2005 gives competent adults over the age of 18 the right to make an Advance Directive to refuse specific medical treatments.  Yet, my local investigations suggest that as of 11 October 2007 there does not appear to be any counselling service to inform and guide those contemplating such a drastic decision.  The only information that I was offered was the text of the 2005 Mental Capacity Act.  I was therefore unable to assess whether someone contemplating an Advance Directive would have to spend as much time as I have done to inform themselves of relevant aspects.  So, I have jotted some notes for myself here and hope that others would point me in the right direction.
Advance Directive An Advance Directive may be precipitated by observations of the experience of others.  Many people, especially the young, tend to fear the worst when they see people after horrific accidents or patients in intensive care.  I have heard many people say that if they were in that state, they would want someone to pull the tubes out.  A 20 year old who resuscitated his father after a traumatic accident now wishes that he had not done so.  He feels guilty that his deed has condemned his dad to a vegetative state for life. The young man, without waiting to see how his dad's condition might develop, could elect to refuse his own resuscitation.  Although these are rare cases, they point to a need for education and counselling.

 

Issues of life and death become more important for the elderly, especially those concerned about failing health and/or faculties.  Some old people grow weary of life for a variety of reasons.  Others are plagued by fear of unbearable suffering and possible lack of access to personal services and palliative care (see WHO definition) due to financial or other reasons.  Such fears and anxieties become exaggerated especially when someone is suffering from illness and/or depression and when they hear of cases of refusal of fully-funded continuing care and of people having to sell their homes to pay for care.

 

End of Life Care Plans are being devised to guide terminally ill patients and their families through the last days of life.  The proforma will give eligible patients with mental capacity the opportunity to review their Advance Decision periodically.  Even when the patient becomes mentally incapacitated, the doctor has to assess the validity of the Advance Decision using prescribed guidelines.  Priority is therefore given to establishing beyond doubt that the patient is still able to confirm the Advance Decision.  However, if the patient is no longer able to communicate, the Advance Decision to refuse treatment becomes legally binding.

 

The Mental Capacity Act 2005 also refers to the need to give Lasting Powers of Attorney over financial matters to trusted individuals and/or professionals before losing mental capacity.  Like me, a growing number of people are beginning to realise and fear that they may have to give such powers to professional(s) who may be total strangers.  Charitable organisations are also becoming increasingly concerned about the growing scope for fraud of the elderly. Quite often the perpetrators of fraud are the very people (family members, friends, solicitors and accountants) appointed as attorneys to look after the best interests of those who become mentally incapacitated.  Crispin Ellison of the Institute of Legacy Management thinks that 'The future scenario is frightening'.  (See Guardian Unlimited, Sunday April 4 2004).  The lone childless elderly person is inclined to feel especially vulnerable and fearful.

 

There is also the fear that one's mental capacity may be misjudged.  Many elderly people get confused about some aspects of their lives but are quite coherent in other respects.  So, when and where should the line be drawn with respect to the loss of Mental Capacity?  To what extent can loss of capacity be due to transient illness/stress/trauma, medication and other incidental factors?  Many elderly people often regain capacity after recovery from an illness.  Should the current state of mind of a patient become irrelevant simply because they have lost the capacity to reason and communicate?

 
The attorney An Attorney cannot overrule the Advance Directive to refuse treatment.  Where there is no Advance Decision, an attorney may have the right to refuse treatment.  Concerns have been expressed over why an attorney may refuse treatment.  Reasons include:
  • Fulfilling patient's informally stated wishes.
  • Projection of what one would want if in that situation, which may not be what the patient wants.
  • Convenience, to end the physical, emotional and financial drain on the family.
  • Impact on inheritance
The medical profession Doctors have to assess:
  • patient's motive; cry for help or depressed state of mind of the patient; not wanting to be a burden on carers when there is a shortage of hospice care; and reasons other than unbearable suffering, which is itself subjective.  No matter what the person's motive might have been, if there is a valid Advance Directive, it is legally binding.
  • mental capacity, assessment of this is often not as straight forward as it may seem given psychiatric tendencies.
  • loss of mental capacity, especially given the scope for regaining capacity.    Advances in neuroimaging already enable us to detect that some parts of the cortex are functioning in vegetative patients, indicating when there is an awareness of pain.  Research is also differentiating the neural correlates of the vegetative and minimally conscious states.  Hopefully, such 'mind-reading' neurotechnology will soon relieve doctors and attorneys of responsibility for making subjective assessments of consciousness and mental capacity   There have been instances of miraculous, sudden recovery of even speech.  The case  of Terry Wallis (reported in the New Scientist in 2006) who spoke after 19 years provides evidence of neural plasticity; i.e. the capacity of a damaged brain to recover functions by re-wiring itself.  I am aware of two cases where sympathetic and simple alternative therapy has helped patients regain control (I will document the cases and therapy in due course).
  • remaining lifespan,  Such prognosis is far from an exact science (para 118 & 119).  Different doctors may base their judgements of terminal illness and remaining lifespan on different criteria and many patients have outlived the prognosis by even 18 months.  Also, it is difficult to prognosticate about the progress of diseases, such as motor neurone disease (p 121).
  • unbearable suffering, is ultimately a subjective experience, which has to be assessed objectively by a doctor.  The suffering may be due to a loss of control and dignity - not just physical pain.
  • best interests of patient; most acts of voluntary euthanasia in Holland and Oregon are carried out by GPs, who tend to have known their patients over a long period of time.  The situation in Britain is quite different, people register with a practice and not a particular GP.  People, like me, who make rare visits to the GP, have noted that most GPs view of them is based entirely on notes left bybothers on their computers.  The doctor who is on call out of normal hours is unlikely to be from the practice (para 159).  A frequent complaint is that no one doctor assumes responsibility for the patient. So, the kind of doctor-patient relationship needed to assess the patient's best interests does not appear to be common in England.   (I will find out more about GP Practice mission statements and report my findings).  We no longer have a family doctor, let alone a family solicitor - another professional who is often called upon to assume power of attorney in many cases.
Future trends 
  • social trends;  In Oregon, it is no longer a matter or whether euthanasia is right or wrong - it is now the law of the State and those who are eligible for hospice care are also eligible for assisted suicide (para 155). "To qualify under the Medicare system, a terminally ill patient must gain access to a hospice programme, which itself depends on a prognosis of six months or less of life remaining"... Ms Jackson confirmed that entering a hospice involved waiving the right to curative treatment ... the reasons for this "difficult disconnect between the curative focus and the comfort focus ... are largely financial." (para 157).
  • medical ethics, there is danger of a drift from regarding the death of a patient as an unavoidable necessity to regarding it as a morally acceptable form of therapy;  pressure will grow as a result for euthanasia to be applied more widely—for example, to incompetent people or to minors ... in the patient's best interests.  Indeed, relatives have openly complained that doctors should have let their loved ones die (The Insider:  Let them Die, Channel 4, 7.30 pm Fri 6 Apr 2007).
  • increase in involuntary euthanasia;  The slippery slope argument suggests that safeguards would be eroded either by subsequent amendments to the law, or by abuse of the provisions in the law or by undesirable changes in medical ethics.  The paper by Roger Woodruff, entitled Euthanasia and Physician-Assisted Suicide Are They Clinically Necessary?, is quite revealing of attitudes and trends.  He makes the point, in para 10.4 with evidence quoted in the text, that in Netherlands (for example) medical homicide is becoming more acceptable as judged by the penalties imposed.
  • funding for continuing care;  recent practices have made funding a bit of a postcode lottery, making euthanasia seem like the only option for some while others engage in protracted litigation.   The devolution of budgets and decision-making to local bodies (SHAs and PCTs) without the provision of national frameworks have made a mockery of the government's mantra of "patients' rights and choice".   Following the Coughlan and Grogan cases, the government in response to the Health Select Committee Report on Continuing Care, undertook the National framework for NHS continuing healthcare and NHS funded nursing care in England: A consultation.  The period of consultation is over and a statement is due.  So, Lord Joffe was indeed correct when he said that autonomy is about choosing between the options available to you.  A more sensible system for administering continuing care, including palliative care, could make assisted living more attractive than assisted dying.

    On a more positive note:
  • accidental breathroughs;  Homeopathy works on the Law of Similars, i.e. that a remedy which causes a symptom in healthy individuals can be used to cure those afflicted with the symptom; see my article on Complimentary Therapies.  It is now being reported (see Daily Mail, 30 Oct 2077) that the sleeping pill had woken up people who had been in coma. 
  • advances in technology; we live in an age of unprecedented technological change.  Not only are there rapid advances in medicine, technology also enables severely handicapped people, such as Professor Stephen Hawking who suffers from motor-neurone disease, to expand their own physical and mental horizons if they have the personal and financial resources and support.  Rapid advances in neuroimaging, have already led to neuroprosthetics, such as the cochlear implant.  Researchers at Brown University have already tested BrainGate, a brain-to-movement system which uses implants to enable someone paralysed in all four limbs to control movement by thought alone (Daily Mail 2006).  Research on motor neuron extensions at The Salk Institute is seeking  to help restore movement in people following spinal cord injury, or those with motor neuron diseases such as Lou Gehrig’s disease, spinal muscle atrophy, and post-polio syndrome. 

The future need not be bleak.
Mystery

Our understanding of the brain and mind is only partial and the mind remains a mystery.  We should not assume that those lacking mental capacity are lacking 'quality of life' or an instinct-driven mission. 

 

We are now legally entitled to say that we do not want lives to be prolonged needlessly.  As noted earlier, this is different from the active ending of life.  Since the outcome of treatment refusal remains uncertain, this need not conflict with a belief in the sanctity of life.  This option is like religious mystics choosing to leave the safety and familiar setting of their homes and exposing themselves to a multitude of dangers living as hermits and as wandering ascetics. 

 

These renunciates aim to free the mind of worldly bondage (mindsets and obligations) and many abandon even their religious teachings and moral preconceptions.  For these are all mental constructs, which are not necessary to gain insight of one's nature within an antecedent all-pervading Divine.  Like light, we may have a dual nature - as particular beings limited by personal constructs, and as transcendental entities with no need for mental capacity as normally understood. 

 

Modern living makes it very difficult for the spiritual aspirant and especially for women.  The lives of those with mystical leanings run cross-grain to the mind-sets being forged by all sorts of vested interests.  Physical and mental incapacity, brought on by terminal illness or accident, provides a window of opportunity to free the mind of irrelevant worldly obligations and concepts and make that connection with our primal self.  As Lord St John of Fawsley pointed out at the House of Lords (see 12 May 2006 : Column 1196), the last period of life is not a wasteland necessarily.  Even if one rejects metaphysical concepts, this period can be a wonderful period of renewal, reconciliation and acceptance as he put it. 

 

The scope for misdiagnosis of diminished mind states is well known.  Hopefully, by giving people the scope for making an Advance Decision requesting passive euthanasia, new legislation will discourage discreet involuntary diamorphine-assisted mercy killing under the cover of the double-effect (see Background: 3).  Such involuntary euthanasia, no matter how well intentioned, robs the mystically inclined of the final hours for accelerated spiritual development.  Hopefully, systems such as BrainGate can be used to curtail the neglect/abuse of responsibility.  Simple yes/no switches should enable patients to verify their state of consciousness and signal their confirmation or otherwise of their Advance Directive after having time to reflect. 

 

Neurologists now believe that left brain cognitive skills - such as logical, sequential and symbolic thinking which we cultivate, habitualise and rely on - can mask more primitive lower-level right-brain skills, such as those exhibited by autistic savants.  Experience of the divine self may be one such primitive instinct.  We know that endorphins are regularly released in the brain and nerves and attenuate pain. Their other functions are still obscure (my emphasis - source: wiki).  We know even less about the subjective effects of psycho-physiological and bio-chemical changes taking place in the lead up to death - these may have a spiritual function.  In much the same way in which heroin derivatives mimic and suppress the body's own production of endorphins (leading to heroin addiction and withdrawal symptoms) they could also distort the natural dying process and its potential beneficence.  Although palliative treatments can reduce mental alertness, modern-day Hindu mystics do accept pain killers and hydration, during meditative fasting in the dying stage (see http://www.bbc.co.uk/religion/religions/hinduism/hinduethics/euthanasia.shtml)

 

For some academic backgrounds on mysticism, see http://encyclopedia.thefreedictionary.com/Mysticism and http://plato.stanford.edu/entries/mysticism/ (esp. Section 8.7).
My tentative conclusion and questions

The right to refuse treatment predates the Mental Capacity Act 2005, which now enables people to make this decision in advance and revoke it later if they so wish.  Their Advance Decision will only be activated and validated if they become mentally incapacitated.  A wide ranging and complex Code of Practice (see http://www.dca.gov.uk/menincap/legis.htm#codeofpractice - Chapter 9) and a number of Guides (see http://www.dca.gov.uk/legal-policy/mental-capacity/guidance.htm) have been drawn up to address reservations and uncertainties. 

 

The mystic view of life is non-judgemental.  It is quite natural for those suffering from unbearable pain to seek relief.  But, like Professor Hawking, mystics believe that "Where there is life there is potential".  They voluntarily relinquish control over their own fate and focus instead on releasing primal instincts, intuitions, emotions, creativity and revelations.  This philosophical view is appealing for a number of reasons.

  • It regards human life as sacred not because of some deontological rule but because of the possibility of attaining a transcendental revelatory state of mind.  This is particularly appealing to those who have had psychic experiences.
  • Such a state of mind, which is not consistent with worldly pursuits, can be intensely pursued at the end of life stage.
  • Just as an infant seeks the mother's breast, and the sex urge rises with puberty, the primal instinct to be One-Self might emerge and might be realised through psychological, physiological and bio-chemical changes occurring at the end of life, unless it is consciously resisted or thwarted by medication.
  • The loss of Mental capacity could well be a part of this facilitating change.  Like butterflies, people too are most vulnerable in their pupal stage.
  • Nature provides for the care of infants (of many species) through timely physiological changes engendering instinct-driven feelings and actions in family and society.  Similarly, the natural process of dying may induce an experience and appreciation of its significance only when the time is nigh.
  • It is a positive view of life in which pain, like penance, is believed to have a mind-liberating function.

Martyrdom and ritual suicides (as in the Japanese Hara-kiri, Hindu Sati, hunger strikes and Buddhist monks setting themselves alight in Vietnam) have deemed even horrific deaths desirable and heroic for political, social and economic reasons.  Yet, one cannot help thinking that that such glorification of suicide may be contrived to veil instincts of frustration, hate and/or fear.  The 2005 Mental Capacity Act is now in force.  But:

  1. Is society ready for its wise implementation? 
  2. Do people contemplating Advance Directives refusing treatment have access to more than nominal counselling and information? 
  3. Are current funding policies encouraging the abandonment of the long term doctor-patient relationships necessary for assessing the patient's best interests and for counselling?  For that matter, should doctors be responsible for death- as well as life-oriented missions? 
  4. Are people being given too little hope and too much rope to hang themselves - i.e. being given autonomy without an enlightening education of consequences and uncertainties?  Who will be responsible for providing the necessary education and how will it be delivered?
  5. What about autonomy for others who want to live?  After having served Sovereign and Country through two world wars and post-war reconstructions, many Britons may not get the care and support they need to gain esoteric experience of dying in a dignified and philosophical way. 

    While endorsing Lord Joffe's view that autonomy is about choosing between the options available to you rather than the ones you would like to have, we can question why assisted-dying should be a legally-binding option when ANH and Continuing Care (which should include Palliative Care) cannot be. 

  6. Should there be a review of the current designation of ANH as medical treatment given that nutrition and hydration are fundamental for existence irrespective of disease?   Should such technicalities justify the asymmetrical application of autonomy - i.e. are some people like Leslie Burke being denied autonomy? 
  7. How can we be sure that there is no abuse of the system, especially where vulnerable people are involved?  Given the ease with which video records can be made and stored, should we not insist that the process of making and witnessing an Advance Directive is video recorded?  Even with blue screen, it is much more difficult to doctor a video than an image.
  8. What about a more positive view of life for those suffering brain damage due to an accident or stroke?  What about funding research into therapies which could induce a re-wiring of brain cells, given that neuroimaging of Terry Wallis and others has now provided evidence of the potential for this.  My father regained the use of his left limbs several months after a stroke when he was 93, just two months before his death in 1996.  A friend who was still only minimally conscious and tetraplegic in May 2007 (more than a year after a brain-damaging accident in April 2006) has recovered motor control of his left side with alternative therapy.  The therapy required active mental participation on his part even when he was unable to exercise motor control.  His slow but planned recovery shows that he not only has mental capacity (even if he is still unable as of October 2007 to communicate), but also that he has the capacity to understand instructions and will his motor neurons to repair themselves primarily through thought.  (see stroke rehabilitation)
  9. What about wider support for the Palliative Care Bill put forward by Baroness Finlay of Llandaff?  Given the cost implications and changing demographics, it is unlikely that government can fully fund the growing need for palliative care.  Governments main role will be in raising awareness and in laying the national frameworks for encouraging greater input from the charitable towards initiatives, such as the hospice movement founded in Britain by Dame Cecily Saunders.  Will the background to the humble beginnings of this now hugely significant undertaking inspire others to go further and support R & D on neurotechnology-based alternatives to a premature and unnatural end to life?
  10. Are we at the start of an exciting new age of discovery?  Putting man on Mars may have significant political and economic advantages for competing nations.  But, advances in neuroscience have already demonstrated the scope for observing the functional behaviour of the human brain and for unleashing and guiding its still unknown and untapped potential. 

Some links

http://www.bbc.co.uk/religion/ethics/euthanasia/

 

 

Mahes Visvalingam 9 Apr 07                                          

Last updated on 14/03/08