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Dr Richard Nicholson is the editor of the Bulletin of Medical Ethics and a retired GP. In this essay, based on his recent talk at the VESS AGM, he examines how far-reaching ethical issues of global concern, whilst initially seeming unrelated, affect they way in which the arguments for and against euthanasia may come to be viewed.
There are now so many different issues in medical ethics, that I often find myself uncertain of my own position on some of them. That can be useful for the editor of a journal, because it means you don’t always end up trying to put in exactly your own views. In the field of euthanasia, I’m not entirely sure what my views are - they may be a little bit confused at times.
Some of you might say that I had won my spurs in the euthanasia field by having had a question asked in the House of Commons by Anne Winterton: she asked the Home Secretary why I was not being prosecuted for murder. I had revealed in a television programme that twenty years earlier I hastened the death of two severely handicapped babies who were being allowed to linger on by their consultant. The situation was causing great distress to the parents and to the nursing staff, so I discussed it with the ward sister. We concluded that we ought to increase the amounts of morphine that these babies were having - because they had severe headaches due to rapidly increasing hydrocephalus.
On the other hand, I find myself wondering just how much of a need there isfor voluntary euthanasia. Is it actually a secondary desire related to the fact that we no longer seem able to care for each other? Now part of the problem lies with the sort of political ethos within which we’ve lived for the past twenty years, which says that the individual is paramount. Nurses as much as anyone else have probably taken this on board and perhaps decided that care is no longer such an important part of their work. Their aspirations have changed as well; increasingly nurses have decided to compete with doctors. They want to achieve the same status by the same route of acquiring fancy degrees and letters after their names. I think that is entirely the wrong approach, because they will always be one step behind. The medical schools take the academically most competent, and so doctors can always stay ahead of nurses academically. What is needed is a far greater emphasis in nurses’ training on assertiveness training, so that they learn how to put over their viewpoint in such a way that doctors have to take note. The problem is that if one allows nurses to go along their present academic route, the dichotomy between cure and care is exacerbated.
I would call cure something impersonal, rather rational and technical, while care is much more about being intuitive and sensitive and emotional. In the NHS, we need both. At the moment, I don’t think we have very much care. There is an emphasis on getting patients better, rather than helping patients to feel better. The problem of care, and of who should provide it within the NHS, is a bit of a paradox. And it is through a series of paradoxes that I want to raise some issues today. I am not trained as a philosopher, but like any good philosopher, I will fail to give you any answers. I will just try to raise a few questions.
I return to the issue of care first of all. I hope you will forgive me for being personal. I want to tell you about my own mother, who had been having a few falls at home in the early part of last year. I rang her one evening as I was about to go to a dinner of the Council of the Royal Society of Medicine. She said she was fine, but some sixth sense told me that she was not. I travelled for an hour or so to where she lived, but could not get into the house because she’d collapsed against the door. I rescued her and had her admitted to the local hospital. And I think now both she and I recognise that I made a mistake. I probably should have left her there.
Since being rescued, she has had a grim time. She spent ten weeks in hospital. Although she had almost certainly broken her shoulder, in the whole of that time I never managed to persuade the doctors to X-ray it. It took me four weeks to persuade them that, if every time she moved she was literally crying with pain - and this is a woman who had had back pain all her life after an adolescent injury - she needed more pain relief. But it took four weeks before they would giveher morphine, and she could start moving. Meanwhile she had been given only codeine, so she was severely constipated. Absolutely no help was given to keep her mobile. Finally, after 10 weeks, we moved her to a nursing home. Perhaps some of the nurses actually felt rather ashamed, because on the last night they managed to give her the only bath she had had in the whole 10 weeks in the district general hospital.
After a few months in the nursing home, she developed a large swelling around the knee that had an artificial joint in it. I tried for months to get either the GP or the local orthopaedic surgeon interested in what seemed to be a large haematoma, but failed. Now she is back in hospital because that haematoma became infected, and is an enormous abscess. She has had enough. Increasingly, over the past few months, every time I see her she just says to me: “Why don’t they let old people like me just snuff out? Why do we have to carry on?" Her husband died six years ago, and she wants to be with him. So the first paradox I have to face at the moment is: do I leave her where she is, back in that hospital where she had a ghastly time last year, and which she hates, because there is quite a good chance that the fourth rate care she is getting there will kill her? Or do I move her out to somewhere where she will get good care, but which will probably prolong her life? It may seem flippant, but I find that a serious paradox.
My next paradox is to raise the question of why there is such a difference between public opinion, as measured by opinion poll after opinion poll, on voluntary euthanasia and physician assisted suicide, and medical opinion. We tend to have something like 80% of the public now in favour of voluntary euthanasia, but many fewer doctors. Is this just because it is the doctors who would be expected to do the killing? Is there indeed any automatic reason why it should be doctors who have to assist in bringing about euthanasia? In the United States, for instance, they don’t use doctors for lethal injections for capital punishment, although that is a fairly horrific process. Or is the reason to do with control, with power? It is interesting that it is always the leaders of the medical profession who come out most strongly against legalising euthanasia. Is it because they are fearful of losing what is really, for the medical profession, a very important power - the power over life and death? It reminds me of the surveys one has seen over the past 20 to 30 years, about patients and information. The vast majority of patients want to know if they have something seriously wrong with them; even if it is cancer, over 90% want to know. Yet, when the same studies are done with doctors, a lot still say “Oh no, you shouldn’t always give patients full information." We have seen a change in the last couple of decades, but not enough. Have we seen any change yet in how doctors view their power over patients in a field such as euthanasia?
Perhaps the greatest paradox of all in relation to euthanasia is: how is it that at the end of the most murderous century in human history, voluntary euthanasia remains illegal? Over 200 million people worldwide have been killed by deliberate human intervention since 1900. That is one eighth of the world’s population in 1900. Yet almost anywhere in the world, people who with good reason want to end their own lives are not permitted to gain any assistance in doing so. How are we valuing human life? Why is life regarded as so much more sacred than death? Surely we should regard death as being as sacred as life, because it is an integral and inevitable part of it. It is curious that the rich western countries with the facilities to do so, do not respond to the murder on a grand scale that carries on around the world. What happens in an African country when civil war, perhaps with genocidal implications, blows up - Rwanda, Liberia, Sierra Leone, or either of the Congos? We extract our own westerners, and then leave them to it, as if we did not care about the loss of human life, because it is only white skins that we have to worry about.
We have seen a change in the last couple of decades, but not enough.
Have you wondered either about our lack of reaction to what is happening in North Korea? We condemn Stalin nowadays for starving the Ukrainian kulaks, because that was a politically motivated genocide. Now the North Korean leaders are doing exactly the same, preventing any food available through South Korea and elsewhere coming into North Korea for political reasons, so that over the next year to 18 months we may well see over a million North Koreans starving to death. Already it is thought that thousands a week are starving, but we do nothing. We are signatories to international conventions on prevention of genocide that commit us to do everything possible to prevent genocide, but we do nothing. Regardless of universal declarations on human rights proclaiming that everyone is born equal and has the same rights, it seems that human lives are worth more in our own country than anywhere else.
That defines another paradox, which is that the right to justice, to be treated equitably, seems to apply only within one’s national boundaries. How can it be that such a basic right, which is revered by political scientists, philosophers, theologians, and everybody who talks about human rights, seems to apply only to one’s own people and not to humans across a border, just a mark on a map away?
We constantly hear that we are now one globe, but many of the implicationsdo not seem to have been taken on board. In the rich countries we control the way in which the free market economy functions, and ignore the damage that it does to many parts of the world. I find it interesting that there are bishops in many parts of the Third World who pray daily that the western free market economy should collapse, because they see the results of it day by day. Those results are that, while the rich countries become richer, many poor countries become poorer, not just relatively but in many cases absolutely. Yet whether one makes comparisons within a country or compares one country with another, the less money there is the poorer the health will be.
The free market causes other distortions. Look at Kenya at the moment, facing famine, particularly in the north. Yet where do you get most of your cut flowers from? Many come from Kenya. So there are the Kenyans, having to grow flowers for us in order to get some money to pay off the debts which we imposed on them, while their own people starve. Take the examples of parts of India and Indonesia, where malaria has increased, in some cases by up to about sevenfold. The reason? The French like eating frogs’ legs. So about 250 million frogs a year are imported from those particular areas. Without them to feed on the mosquitoes, malaria rises - so that we can live our nice consuming, contented lives.
Since 1950, world population has increased by just over 120%. The need for grain has increased by 200%, consumption of seafood has increased by 300%, paper use has gone up by 500%. We are using more and more of what the world has available to us. But what is important is where it is being used. In the industrial world, the OECD countries, we use about 20 times as much metal per head of population as do the other six-sevenths of the world’s population, 14 times as much paper, 10 times as much energy, 3 times as much water. But the figure which is never given on these comparisons is that of health care. By virtue of being the richest countries, we are the healthiest, yet we still find it necessary to spend 50 times as much on health care as the other six-sevenths of the world put together. And what do we get for that? We probably think that we get a lot of good health care out of it. Life expectancy in a country like ours has certainly gone up by 30 years this century. But few people realise that only three of those 30 years are the result of all the improvements in medical care. The other 27 years are due to improvements in social conditions: better food, universal availability of clean water, sewage disposal, and so forth. Of the 3 years extra life expectancy that modern medicine gives us, half is due to childhood immunisation. It is only about 18 months that is provided by all the panoply of the NHS. Sometimes I think we ought to be asking: is it worth it? Is it worth our having that when in parts of rural Africa, fewer than 30% of the people have access to clean water?
A variety of major problems faces humanity. Overpopulation is one, environmental degradation is another. These are problems which we all recognise all the time. But there is a third one - overconsumption of what the world has in the way of resources - and that is the one which applies to us. We may think we can do very little about overpopulation in other parts of the world, we may do our little bits about trying to improve the environment, but the part where we are all at fault - and I include myself in this - is in overconsuming what the world has in the way of resources. The consequences, in the long term, may be very grave indeed for some countries. There is a condition known as demographic entrapment, when a country can no longer feed itself, and is rapidly degrading its environment. The result is progressive starvation, death from disease and increasingly rapid environmental degradation. Countries like Nepal are there already. What perhaps is alarming is that countries like Pakistan will be there very soon. Pakistan will soon be the third most populous country in the world: it is likely to have a population of over four hundred million by the year 2020. Meanwhile, even within countries, you find that the rich become richer and the poor become poorer.
Let me mention another paradox about our economic behaviour, which I have never understood. How is it that one can aim as a nation to have economic growth continuing indefinitely when we live in a finite world? This is difficult to understand until you look, for instance, at the World Bank’s Development Report. There you find the evidence that in any given period recently, half the countries of the world do not have growing economies but shrinking economies; those are the poor countries, the countries of Africa and South America and Asia. In the last World Development Report, of the 104 countries for which information was available, 47 had a shrinking level of Gross Domestic Product.
Why do I feel that this is of relevance to you as proponents of voluntary euthanasia? Because of my final paradox, which is that as we strive for ever longer individual survival - which seems to be what health services in the west are about, and what a lot of peoples’ ideas of life are about - we decrease the chances of the human race itself surviving. That may seem a bit extreme. But if you put a technological explosion and an explosion in consumption in one part of the world, and a population explosion in all the rest of the world, you do not create a stable globe. I fear that if we do not moderate our consumption very soon, there may be some absolutely cataclysmic results. One thing that we do provide to these overpopulated countries are the means of communication, so they see what they are missing out on. There may be people in a country like Pakistan, just as there are people in our own country, who would say: this is becoming so unreasonable and so unfair that we ought to do somethingabout it. The means are now readily available to do something. It doesn’t have to involve nuclear weapons; we have already seen an example of biological terrorism in Japan.
Many countries, for instance, would have little difficulty in producing a large amount of anthrax. All that would be required would be a crop-duster plane to spread anthrax spores over half a dozen of the major cities of the world and you would probably bring the free market economy to its knees overnight - as well as making those cities uninhabitable for the next twenty years. If we continue to put pressure on poor countries by thinking that we may consume endlessly while leaving them to pick up our scraps, we increase the danger that such a cataclysm might happen.
I don’t see any other way forward than in trying to reduce our consumption, in trying to reduce what I think is actually greed. The Conservative government was entirely wrong in promoting the idea that people should just get whatever they can for themselves. In our own sphere of interest, we need to moderate our greed for life, for longevity. I don’t see any religious or other justification for that greed. I don’t see anything in the Bible which tells us that we’ve got to try and live as long as we possibly can. There is much more about the quality of the life we try to lead. If I can quote Dan Callahan, who is a well known American bioethicist and a Catholic, “In the name of medical progress, we have carried out a relentless war against death and decline, failing to ask in any probing way if that will give us a better society. The proper question is not whether we are succeeding in giving a longer life to the aged. It is whether we are making old age a decent and honourable time of life. Neither a longer lifetime nor more life-extending technology is the way to that goal.” And there is another American bioethicist, called Paul Menzel, who recently wrote, “Let’s just take a few of the gloves off our moral language here: dying more cheaply is not just admirable sacrifice; sometimes it is morally required.”
I think there may come a time soon when, if one undertakes a global utilitarian analysis, it would show that voluntary euthanasia is an absolutely essential part of any society’s way of coping with old age and death. There are places where that happens already, quietly. I was intrigued a few years ago, when I was teaching a human rights in medicine course in Yugoslavia, that whenever there were any senior Yugoslav doctors present the public discussion was always that euthanasia was absolutely taboo. But after the session a GP from Montenegro came up to me and said “Don’t believe a word of what you have heard. Up in the hills in Montenegro, it has been accepted for many years that old people, when they feel that they are no longer of value to the village, when they are becoming a drag on their families, will go along to the family doctor in that village, and he will provide them with what they need to end their lives.”
If we are to help ourselves create a stable globe, using only our fair share of the world’s resources, that will have to become common practice in our country too.
The talk was followed by a lengthy discussion, in which Dr Nicholson responded to questions from the audience. As well as allowing members of the audience to have their say, this also afforded Dr Nicholson the opportunity to expound on the opinions contained in the talk. He sought to put his arguments into perspective by pointing out that were the NHS budget to be cut in half, this could be done in such a way as to result in only around 5000 extra deaths a year in Britain. This would, however, provide approximately the amount of money which UNICEF has been seeking for the past eight years to finance a global programme of immunisation and primary education, and to provide clean drinking water for all children. This, UNICEF claimed, would save the lives of an estimated four million children worldwide annually within 10 years, as well as reducing the growth of overpopulation in these countries (primary education for girls being the single most powerful factor in reducing fertility rates).
He stressed, though, that he was not advocating the use of euthanasia for ‘culling’ those who are no longer productive. However, he expressed the view that there are in western developed countries a lot of old people who really feel that they have lived quite long enough, for whom life holds very little, and who would prefer to be out of this life. It would be foolish for a society wishing to enhance the stability of the whole globe to say that we have to carry on doing everything possible, using up the world’s resources, on people who don’t want to continue to exist.
© 1997 VESS
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