Choice at the end of life

A bill to legalise voluntary euthanasia and assisted suicide is currently being considered here in New Zealand. Passionate campaigners both for and against have put forward compelling reasons to support their case. At one extreme are those who believe that human lives are sacred and only God can determine when they should end. At the other extreme are those who believe that each individual has the right to control the timing of his or her own death. Logically it is not possible to agree with both views, but perhaps there is scope for some compromise between them.

The term euthanasia, according to its Greek origin, means a “good death”. Much as I dislike the idea of deliberately ending a life, I do think there is a place for assisted dying for patients who are already finding their situation unbearable, or who wish to avoid likely suffering and loss of dignity in the future. But such cases are a minority. When I was in medical practice I got to know many patients with terminal or incurable conditions, mostly advanced cancer, and I do not believe that most of them would have wanted euthanasia or assisted suicide even if these options were legally available – though I remember a few who did. Similarly, recent surveys have found that many people with severe permanent disabilities have no desire for euthanasia, and are often worried that they might be pressurised into having it if the bill becomes law.

There are some strong arguments against euthanasia, but I think they need to be qualified. Looking at some of them in more detail:

“Euthanasia goes against the sanctity of life and the will of God.” This is the position of the Catholic Church and many other religious traditions. While respecting this belief myself, I do not think it justifies withholding the option of euthanasia from those who hold a different view. For this reason, when an anti-euthanasia submission was recently presented to our local congregation after Mass, I did not sign it.

“There is no need for euthanasia because symptoms and suffering can be so well controlled with modern palliative care.” I disagree with this one. Only a minority of dying patients have access to specialist palliative care. Even with the best of care, there are a few terminally ill patients whose symptoms and suffering cannot be relieved. And what about old people who may not have any specific life-limiting disease but would welcome death to release them from weakness and frailty, aches and pains, failing physical and mental faculties, loneliness and lack of purpose?

“Euthanasia may be undertaken too lightly, and against patients’ real wishes.” This is a real risk. Some people will feel obliged to request euthanasia to avoid being a burden to others. Well-meaning medical staff can judge that some patients’ lives are not worth continuing, when the patients themselves might disagree. This can also apply to the withholding of life-sustaining treatment, which could be called passive euthanasia. I have just read It’s Not Yet Dark, a memoir by the late Irish film maker Simon FitzMaurice. He describes being discharged from a hospital without being offered home ventilation because doctors had assumed that someone with his diagnosis, namely motor neurone disease, would not want their life prolonged. In his case they were quite wrong, and he was able to obtain a ventilator and spend several more worthwhile years with his family. A less informed and articulate patient could not have achieved this.

“There could be deliberate abuse.” Going further down the “slippery slope”, legalised euthanasia could provide a cover for murder. Family members might want to dispose of a sick or elderly relative, in order to make their own lives easier, or to get hold of an inheritance. Euthanising incurable chronic patients, who require expensive and time-consuming care, could be said to enable the more efficient use of scarce health care resources. Recent history has shown the potential for mass killings by authorities in the name of racial cleansing or medical research.

“There can be psychological damage to the staff involved.”  The same applies to clinicians carrying out abortions, and veterinary surgeons putting animals to sleep. There is certainly scope for conflict and distress when those trained to preserve life are called upon to end it, depending on whether they believe they are doing the right thing, and on the method used. Prescribing a fatal quantity of drugs, for the patient to take at a time of his or her own choosing, would seem a less harrowing experience for a doctor than administering a lethal injection – although the end result would be the same. Besides affecting staff, unnatural deaths can have a deep impact on the family and friends of the deceased. Consenting to euthanasia of a sick pet, and hearing about the suicide of a colleague, have counted among the most distressing events in my own life.

In summary my own view is that euthanasia and assisted suicide can be justified occasionally, though literally as a last resort, on condition that the patients concerned have given informed consent; if other treatment options have been carefully considered and excluded; if clinicians with religious or ethical objections are not obliged to take part, and if there are safeguards against abuse of the system. I suspect that many people who support euthanasia in theory might sign up in advance when still in reasonable health, then decide not to go through with the option when it actually came to the point – but having a sense of control is a very important aspect of coping with illness, and I believe patients should be allowed that choice.







Book reviews: the good, the bad and the ugly

I depend almost entirely on reviews for discovering books that sound interesting and enjoyable to read. The best reviews, I think, provide a balance between a factual description of the book and the personal opinions of the reviewer. They usually include a summary of the content, though in the case of a novel it is infuriating when they reveal too much of the plot. There is also a discussion of the context, perhaps citing similar books and filling in the historical or cultural background, acknowledgement of the book’s good points and constructive criticism of its flaws. Writing a review, as I was sometimes asked to do during my former academic career, is quite an art. It takes a lot of time to read through the book and take notes, perhaps do some research about its subject-matter, and then compose a piece that is fair to the author and will hopefully prove interesting and informative for potential readers.

The detailed reviews in quality publications such the Listener, Spectator and Literary Review are often worth reading as essays in their own right, even when the books in question do not appeal. Many of the shorter reviews on public platforms such as Amazon and Goodreads are also well written and thought out, but a few of them represent individual opinions of an extreme kind, ranging from lavish praise to abusive condemnation. Some of the good ones have been paid for by the authors; some of the bad ones say more about the prejudices of the reviewer than about the book itself.

Many books never get reviewed at all, so from the authors’ perspective perhaps any review is better than none for publicity purposes. However, all but the most stoical authors feel a certain trepidation before looking at their reviews. Some have been so badly angered or upset by reading them that they no longer do so. While most of my own books have received positive reviews, and these are highly gratifying, it is the occasional negative one that can stick in the mind and feel soul-destroying. And it is baffling when there are completely different verdicts on the same book. Having recently been devastated by a 1-star rating of my Three Novellas on one site, I was comforted to find on its Amazon UK page a 5-star rating with the comment “Jennifer brings together all her experiences from previous work to produce a superb trilogy finishing with an interesting twist.”

I would encourage reviewers to be kind as well as honest, remembering that all books have both good and bad points, and that those they hate might be loved by someone else and vice versa. Personally I no longer post ratings or write reviews for books I dislike, but prefer to give up reading them and move on to something else.