THE debate on euthanasia and assisted suicide is seldom far from the public eye. We have had a controversial documentary, "Right to Die", showing the death at the Dignitas clinic in Zurich, of a patient with motor neurone disease. More locally, there has been a repeat TV screening of MSP Margo MacDonald's documentary about assisted dying and news coverage of the launch of her consultation paper which she ultimately hopes will lead to legalisation of assisted suicide in Scotland. Over the years that I have been involved in the debate, I have seldom if ever seen one side convincing the other, so this article probably will not win any converts. The convictions about the rights and wrongs of the issues are deeply held. It does worry me though that these convictions sometimes seem to be founded either on gut feelings about our personal rights, or other gut feelings that it contravenes some sort of basic religious or moral code, rather than being well informed by practical realities. When it is presented simply in terms of my right to a dignified death, how could anyone disagree? To quote Margo MacDonald: "... all of us have the right to die with dignity and only we ourselves can determine when life is intolerable." Surely any opinion to the contrary must be irrelevant, probably originating from a stuffy, conservative medical profession or from religious dinosaurs, neither being prepared to embrace a progressive concept for modern society. And surely in this day and age we can devise legislation to enable the safe adoption of this ultimate act of compassion into standard medical practice! Assisted suicide? Dying with dignity? Of course! Why on earth not? I find it disturbing that the word "dignity" in this context has been hijacked so that it is now regarded as synonymous with euthanasia or assisted suicide. The Voluntary Euthanasia Society has been rebranded as Dignity in Dying, and if you go to Zurich to end your life, it is to the Dignitas Clinic. The implication is that medical care which does not include assisted suicide or euthanasia therefore lacks a fundamental component of dignity. When I came across a paper in a medical journal about the meaning of dignity for cancer patients attending a hospice, I read it avidly to see what these patients had to say about assisted suicide and euthanasia. Dignity for these patients was all about relationship and belonging, having control over what is happening, being valued and esteemed, and maintaining individuality. To my surprise, nowhere did these patients interpret these factors in terms of choosing their time or means of death! Professor Harvey Chochinov, who spoke on the issue at Highland Hospice's 20th anniversary conference last year, has written eloquently on dignity in medicine, the substance of which is found in our attitudes towards our patients, our professional approach, the quality of our communication, and the compassion which must underpin all of this. I find this to be so relevant in my everyday work amongst patients with advanced and incurable disease the very people who are allegedly clamouring for legalisation of assisted suicide or euthanasia. My patients want to be looked after by competent clinicians but the thing they really value is the care with which their treatment is delivered. Maybe more than anything, that care involves time; time spent in discussing the illness and how things are going to progress; time spent explaining the treatments and what can be expected of these; time taken to explore worries, fears and distress; the time involved with explaining things to families so that they too feel valued and dignified. My favourite quote comes from an American physician from the 1920s, who said: "The secret of the care of the patient is in caring for the patient." How true! What patients want in response to their distress is loving, compassionate and competent caring rarely physician-assisted suicide or euthanasia. But rarely does not mean never. Very occasionally patients will express a wish that their lives could be ended. Often that is an expression of distress rather than a considered request, and there is a well recognised association between this and depression, something we can improve with treatment. Others will mention it because they fear uncontrollable symptoms as the illness progresses, and we can often lessen these fears by reassuring our patients that modern symptom control is of high quality. That leaves a tiny proportion of the patients that I see who express a considered and persistent wish that we should end their lives. Interestingly this never arises because of actual pain, but rather from the overall distress of their suffering. I am quite prepared to discuss this with them in a non-judgemental way, but I acknowledge that I may not be able to alleviate this suffering. The huge problem is that if, for this tiny minority, I was to have the option of providing assisted suicide, my ability to openly acknowledge and address the concerns of the majority would be severely compromised. Patients, already fearful and vulnerable, would simply not be able to talk about their distress without assisted suicide being on the agenda. Fears thus suppressed would fester. The needs of the majority would have to give way to the wishes of a minority. I am a doctor, not a lawyer, so I can only make limited comment on legal aspects of all this. There is far from unanimous agreement amongst our legislators that the law in Holland and Oregon, where such practices are legal, is safe. In the Netherlands, a significant number of people have their lives terminated without their explicit consent and whilst statistics suggest that the incidence of euthanasia is falling, what is actually happening is its replacement by "terminal sedation" by which patients are given drugs which sedate them continuously and deeply until death. Recently an enquiry commissioned by the Royal Dutch Medical Association concluded that doctors can help patients to die even though they may not be ill, but "suffering through living" whatever that means! In Oregon, physician-assisted suicide has been legal for several years but remains highly controversial and official reports acknowledge that the legislation does not safeguard against illegal practice by doctors. In a very insightful quote Lord Carlile says: "Laws aren't like precision-guided missiles. You can't draft them in the comfort of a Westminster chamber and then just 'fire and forget'. Once they are on the statute book they have a habit of causing collateral damage well beyond the intended target area. With something as fundamental and as crucially important as the safety of us all as the law on murder, you need to be quite sure that the law is defective and needs fixing, and that the provisions you are making are robust enough to stand up to the rough and tumble of the real world. In real life we have to design laws which protect the greatest number of people, and especially the vulnerable members of society. And that is what the law as it stands does." Physician-assisted suicide and euthanasia are serious issues that are not going to go away and we need to know what we think about them. But that is the operative word think this is no lightweight matter for knee jerk responses.
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