Statements on Euthanasia and Physician Assisted Suicide

Global Statements on Euthanasia and Physician Assisted Suicide

Reviews by PC professionals on Ethical Issues are welcome. Publication on the website will be at the discretion of the Executive Committee of IAHPC.

International Organizations

AUSTRALIA

The Australian Association for Hospice and Palliative Care, Inc.

VOLUNTARY ACTIVE EUTHANASIA-POSITION STATEMENT OF THE AUSTRALIAN ASSOCIATION FOR HOSPICE AND PALLIATIVE CARE INC.

The Australian Association for Hospice and Palliative Care:

1 defines Hospice and Palliative Care as a concept of care which provides coordinated medical, nursing and allied services for people who are terminally ill, delivered where possible in an environment of the person’s choice, and which provides physical, psychological, emotional and spiritual support for patients and for patients’ families and friends. The provision of hospice and palliative care services includes grief and bereavement support for the family and other carers during the life of the patient continuing after death;

2 defines Voluntary Active Euthanasia (VAE) as the deliberate action to terminate life by someone other than, and at the request of, the patient concerned;

3 believes that dying is a natural process and that the refusal or witbdrawal of futile treatment is not voluntary active euthanasia;

4 believes that legalisation of voluntary active euthanasia is not a substitute for the proper provision of palliative care services to all Australians; 5 believes that public interest in voluntary active euthanasia reflects a concern about lack of adequate support for people who are dying, and will continue to campaign for improved services, education and research in all aspects of palliative care; 6 states that currently accepted palliative care practice does not include deliberate ending of life, even if this is requested by the patient; 7 asserts that palliative care experience shows that appropriate and effective use of morphine and other drugs for pain relief does not cause death; 8 recognises that there is a wide divergence of views about voluntary active euthanasia in Australian society, and also with in the caring professions, including the palliative care community; 9 recognises and respects the fact that some people rationally and consistently request voluntary active euthanasia; 10 acknowledges that, while pain and symptoms can be addressed, complete relief is not always possible in all cases, even with optimal palliative care; 11 welcomes open and frank discussion within the community, and particularly with the health professions, about all aspects of death and dying, including voluntary active euthanasia; 12 nevertheless, due to the inherent risk to individuals and society, opposes all legalisation of euthanasia. 27 October 1995 For further information please contact : Australian Assoc. for Hospice and Palliative Care , Inc. PO Box 7450, Cloisters Square, Perth WA 6850 Tel: (09) 324-1001 Fax: (09) 324-1002

NORTH AMERICA

USA

American Academy of Hospice and Palliative Medicine

Hospice and Palliative Nurse Association's Statement in Response to Supreme Court Ruling on Physician-Assisted Suicide

The Hospice Nurses Association, together with the National Hospice Organization and the Hospice Association of America, the country's leading advocates for terminally ill individuals and their families, applaud the Supreme Court's attention to the physician-assisted suicide issue. We express concerns, however, that the decision may raise more questions than it answers.

The question shouldn’t be whether the state has an interest in allowing a person to ask a doctor to help them commit suicide, but whether the state has an interest in helping citizens live out their last days as comfortably and with as much dignity as possible.

Many terminally ill patients turn to physician-assisted suicide not because they cannot be cured, but because they cannot bear the thought of physical pain and depression they fear will accompany a terminal prognosis. When terminally ill patients are given proper medical, nursing and supportive care, the desire for assistance with suicide decreases. Hospice is a comprehensive, medically directed, team-oriented program of care that emphasizes pain control and symptom management rather than curative treatment. It is a philosophy of care that accepts death as a natural part of life, and addresses the psychological and spiritual needs of the patient and family.

Hospice Nurses Association Position on Physician-Assisted Suicide Adopted May, 1994 The Hospice Nurse Association, the organization that speaks nationally for hospice nurses committed to compassionate care of the terminally ill, Having witnessed first hand the phenomena of palliation or relief of pain and suffering and the maintenance of patient/family defined quality of life of dying patients and their families in hospice care, Opposes the legalization of euthanasia and assisted suicide. We reaffirm the hospice concept of care that neither hastens nor postpones the onset of death. In addition, we support all activity toward open discussion, public or private, about these or any other issues that concern hospice patients and families. Finally, we support all public policy changes that would ensure access to hospice care irrespective of patient age or diagnosis and patient/family socioeconomic status.


Statement from the Academy of Psychosomatic Medicine

Academy of Psychosomatic Medicine
The Organization for Consultation-Liaison Psychiatry

POSITION STATEMENT: Psychiatric Aspects of Excellent End-of-Life Care

The Academy of Psychosomatic Medicine (A.P.M.) is the organization of Consultation-Liaison (C-L) Psychiatry. Its international members includes many of the leading clinicians and researchers in the field of C-L Psychiatry, a discipline which focuses on the psychiatric care of the medically ill. This clinical focus includes the psychiatric problems of catastrophically ill and dying patients. Prepared by the A.P.M.'s Ad Hoc Committee on End-of-Life Care, this Position Statement has been approved by the A.P.M. Executive Council in the method described in the constitution and bylaws of the A.P.M. This document is the A.P.M.'s Position Statement regarding psychiatric aspects of care provided to patients nearing the end of life.

1. Psychiatric morbidity at the end of life is significant and causes substantial, potentially remediable suffering to dying patients and their families. Further, we believe that quality care for the psychiatric complications of terminal illness is and should be an integral component of excellent, comprehensive end-of-life care.

2. The most basic challenge at the end of life which stresses patients and families is loss, which is related to both the disabilities of the illness with their threats to self-esteem, and the patient's death, which ruptures the direct relationship with the family. Psychiatric problems and issues commonly seen at the end of life include anxiety symptoms and anxiety disorders, depressive symptoms and depressive disorders, delirium and other cognitive disorders, suicidal ideation, consequences of low perceived family and other social support, personality disorders or personality traits that cause problems in the setting of extreme stress, questions of capacity to make informed decisions, grief and bereavement, and general and health-related quality of life. Spiritual and religious issues, including both personal faith and relationship to a community of believers, are important for most people. Good end-of-life care requires explicit attention to these matters.

3. Studies show that psychiatric morbidity in the setting of terminal illness is exceptionally high. The prevalence of delirium in terminal cancer and AIDS patients ranges from 30-85%, and the prevalence of clinically significant depression ranges from 20-50%. The prevalence of depression among terminally ill patients with a desire for death is eight times higher than in those without a significant de sire for death. Depression is the strongest determinant of suicidal ideation and desire for death in those with serious or terminal illness.

4. Psychiatric complications at the end of life are treatable, but often go unrecognized and untreated. Several factors or barriers contribute to the underrecognition and undertreatment of psychiatric problems at the end of life. These include:

Difficulty in diagnosing psychiatric disorders (e.g., anxiety, delirium, depression) in the setting of significant physical illness, owing to the overlap in the symptoms caused by the psychiatric disorder and the comorbid physical problems.

Beliefs held by many patients, family members, physicians, and hospice and palliative care providers whereby psychiatric symptoms, especially depression, are viewed as normal parts of the dying process.

The fact that many patients and physicians do not understand that patients who suffer from mental disorders at the end of life can respond to treatment. This therapeutic nihilism prevents the search for treatable mental disorders at the end of life.

The presence of structural barriers to coordinated care of dying patients. Psychiatrists may not be readily available to care for terminally ill patients and consult with physicians providing end-of-life care for a variety of reasons. Among these are limited geographic access (most C-L psychiatrists are memberd with academic medical centers in urban areas), psychiatrists who feel inadequately prepared to assess and treat dying patients, healthcare insurance carve-outs (which may limit or exclude access to and coverage for psychiatric care), and logistical obstacles to formal addition of a psychiatrist to a hospice care team.

The stigma experienced by patients and families due to psychiatric evaluations or the assignment of a psychiatric diagnosis. Physicians and other caregivers may share this feeling.

The occurrence of countertransference of hopelessness on the part of families and healthcare providers that may discourage seeking assessment of suffering from psychiatric causes in dying patients and weaken the commitment to helping maintain morale at the end of life.

The fact that treatment based on formal diagnosis (as opposed to symptomatic treatment) is not sufficiently emphasized in palliative care.

5. We believe that the current enthusiasm for legalized assisted suicide and euthanasia at least partly reflects public concern that suffering (including suffering due to psychiatric causes) and distress at the end of life may elude or exceed our best current treatment efforts, making death seem preferable. Appropriately, aggressive treatment for psychiatric complications of terminal illness is the best way to address this fear and should reduce requests for assisted suicide and euthanasia.

6. We maintain that laws and regulations must allow physicians to provide appropriately aggressive care for psychiatric complications of terminal illness and must provide protection for qualified physicians who provide this care. For example, excellent treatment of depression at the end of life often requires the use of psychostimulants, most of which are Schedule II controlled substances. Appropriate use of these agents to control depression at the end of life should be viewed as analogous to the use of opiate analgesics to treat pain in this setting. Similarly, appropriate treatment of agitated and delirious patients who are dying may require sufficient sedation to relieve the suffering of the patient and family. When clinically indicated and acceptable to the patient or surrogate, such sedation is the standard of care and should be employed even if it hastens death. Such treatment is ethically sound and is not an act of assisted suicide or euthanasia.

7. In response to the above, the A.P.M. believes that remedial efforts must be encouraged. These include:

Education about the prevalence and morbidity of psychiatric complications of terminal illness. Target audiences should include the general public, students and trainees in all healthcare professions, and healthcare providers in hospice and palliative care, primary care, and medical specialties (including psychiatry).

Education and other efforts to reduce or remove barriers to excellent psychiatric end-of-life care, as outlined in Section 4 above.

Education and advocacy efforts to insure that legal or regulatory barriers do not hinder or prevent excellent psychiatric care at the end of life.

Clinical (and, where appropriate, basic science) research into psychiatric complications of terminal illness, their effects on suffering and quality of life in dying patients and their families; interactions with other comobid conditions such as pain, fatigue, shortness of breath, anorexia and nausea; and reliably effective treatment strategies used at the end of life. Collaboration with governmental funding agencies and private foundations should be encouraged to develop research in these areas. Particular attention should be paid to training young investigators in research related to the psychiatric complications of terminal illness.

National Hospice Organization

RESOLUTION ON ASSISTED SUICIDE

WHEREAS, The National Hospice Organization is considered the voice of the nation's hospice community; and,

WHEREAS, The National Hospice Organization is often requested to provide comment to the Congress, the Administration, the Courts, the
media and the general public; and,

WHEREAS, The National Hospice Organization is on record as supporting a patient's right to choose palliative care and a patient's right to refuse
unwanted medical intervention including the provision of artificially supplied hydration and nutrition; and,

WHEREAS, There has been increased public attention and focus on the issue of voluntary euthanasia and assisted suicide; and,

WHEREAS, The proponents of change in the legal status of these practices often paint a stark picture in which a patient's choice is between
painful existence devoid of value on the one hand and voluntary euthanasia or assisted suicide on the other; and,

WHEREAS, We believe hospice care is a better choice than voluntary euthanasia and assisted suicide; therefore,

RESOLVED, That the National Hospice Organization reaffirms its commitment to the value of the end of life and to the philosophy that hospice
care neither hastens nor postpones death.

RESOLVED, That the National Hospice Organization does not support the legalization of voluntary euthanasia or assisted suicide in the care of
the terminally ill.

RESOLVED, That the National Hospice Organization supports improved access to hospice care for terminally ill patients and their families,
including those who have expressed a desire for assistance with suicide.

Adopted by the Membership November, 1996

1901 N. Moore St., Ste. 901 Arlington, VA 22209 (703) 243-5900 (703) 525-5762 fax

Copyright 1997, National Hospice Organization, Arlington, VA

CANADA

Canadian Palliative Care Association

The Canadian Palliative Care Association is opposed to legalizaed euthanasia and assited suicide

We call instead for palliative care services to be accessible to all dyiing persons in Canada, their families and caregivers. Comprehensive palliaitive care addresses the pain and suffering of persons living with life threatening illness and their families. In Canada, people have the right at any time to refuse or stop treatment.

The EAPC Ethics Task Force on Palliative Care and Euthanasia
http://www.eapcnet.org/projects/ethics.asp

Following the phenomenal success of the debate raised by the research journal of the EAPC, Palliative Medicine, this task force is nearing completion in its work. The final paper has been published in English and translated so far into French, Italian and Hungarian, with a German, a Finnish and a Greek translation under way.

As a result of this, a number of issues arose over the procedures adopted for the translation of this paper and subsequently reflected the need to revise the translation policy in its entirety. Lars Johan Materstvedt (Chair of the euthanasia task force) and David Clark (working group member and member of the EAPC Board of Directors) worked together on this and have refined the rules of translation which have been agreed by the EAPC Board. In effect, only papers translated in accordance with the rules below will be considered acceptable by the Board, providing a standard of equity and reliability across translations of what can often be complicated ethical and philosophical debates. The revised policy highlights the need for conceptual equivalency in addition to word translation. In the translation of the paper on euthanasia, considerable additional work was required by the authors to ensure that meaning was not lost in the process of translation, particularly where no direct word or concept translation was apparent. The EAPC Board commend the work of this group in addressing this complicated and difficult issue and are grateful for the group’s contribution for the benefit of its members.

EAPC translation policy for the ethics task force on palliative care and euthanasia

The EAPC discourages ad hoc translation. Any ‘unofficial’ translation that may exist should be reported to the EAPC, which will then ask the relevant parties that it be withdrawn, and instead suggest a translation process in accordance with the one described here.

Official translations should be organised in collaboration with the national associations that are collective members of the EAPC.
The EAPC grants the right to publish translations in the scientific journals of the national associations, or similar.
A PDF file of the translation must always be provided for publication on the EAPC website.
The EAPC will nominate the translator of the document.
The Chair of the report will nominate a referee to check the translation.
Referees’ judgements would usually take precedence over those of translators.
Both the translator and referee must be native speakers of the target translation language.
The names of both translator (and any people who have assisted the translator) and the referee must always be given in a footnote to any translation.
In that footnote, the English original paper must also be referenced, with a hyperlink to the full text/PDF version of the original paper, as well as to the task force’s response to critics.
The national association will, after both translator and referee have completed the translation, consult with the EAPC to facilitate translation back into English of all translations.
Finally, after having supervised the work of translator and referee and having checked their work against the translation, the Chair, together with the group of people he chooses to consult, must give approval before any publication can take place.
It is anticipated that translators and referees will work on a voluntary basis. If this is not possible, the national associations will be asked to bear the costs of using an external service, or to provide a translator before commissioning the work.
It must also be noted that English remains the official language of the EAPC and all reports must be presented in English and approved by the Board of the EAPC before any other translation process is undertaken.

1997

Great Britain

National Council for Hospice and Specialist Palliative Care Services
ETHICAL DECISION-MAKING IN PALLIATIVE CARE: Cardiopulmonary Resuscitation (CPR) for people who are terminally ill

This paper has been prepared by a Joint Working party between the National Council for Hospice and Specialist Palliative, Care Services and the Ethics Committee of the Association for Palliative Medicine of Great Britain and Ireland.

Experience has shown that, when drawing up and implementing CPR policies, it is necessary to give particular consideration to the needs of terminally ill patients. It should be noted that good practice suggests that decisions regarding CPR should involve a multiprofessional team, the patient, and relatives and carers, but that the senior doctor has ultimate responsibility for the decision.

1. There is evidence, (1, 2, 3) to suggest that, for terminally ill patients, the harms of CPR are likely far to outweigh the possible benefits. Evidence indicates that, almost invariably, CPR either fails to re-establish cardiopulmonary function, or succeeds only to result in further cardiopulmonary arrest with no intervening hospital discharge.

(a) CPR is inappropriate (4) if (i) there is virtually no chance of CPR re-establishing cardiopulmonary function; or (ii) successful resuscitation would probably result in a quality of life unacceptable to the patient (recognising that the focal point of any such decision would be the views of that patient); or (iii) it is contrary to the competent patient's expressed wishes.

(b) CPR may be appropriate if 5. (i) there is a reasonable chance of CPR re-establishing cardiopulmonary function; and (ii) successful resuscitation would probably result in a quality of life acceptable to the patient (recognizing that the focal point of any such decision would be the views of that patient); and (iii) it is the competent patient's expressed wish. (See Point 5)

2. There is no ethical obligation to discuss CPR with the majority of palliative care patients, for whom such treatment, following assessment, is judged to be futile (1-8). In the context of open and honest discussion, the raising of such issues may be redundant and potentially distressing.

3. If the likely outcome of a CPR intervention is uncertain, anticipatory decisions either to implement or withhold CPR should be sensitively explored with the patient. Both the likelihood of success and the resulting quality of life will be appropriate issues for discussion. Review of any such decision may be appropriate with change in the patients clinical situation.

4. Should a patient be likely to benefit from CPR and would wish for it, the extent of CPR facilities and expertise available in any admitting unit ought to be discussed with the patient, ideally prior to admission. Limited availability of such facilities in specialist palliative care units need not undermine appropriateness of admission in early disease as patients may accept such admission on the understanding that initial resuscitative measures will be instituted and transfer to a unit equipped to undertake CPR will be arranged in the event of a cardiac arrest actually occurring.

5 Consideration should be given to CPR policy early in the involvement of the clinical team. In the absence of an anticipatory decision or a valid advance refusal, at the time of cardiorespiratory arrest, the patient is by definition incompetent to make a decision regarding CPR and therefore it is the doctor's legal responsibility to act in the patients best interests.

Notes (I) "Terminally ill people are those with active and progressive disease for which curative treatment is not possible or not appropriate and from which death can reasonably be expected within twelve months" (from Care of People with Terminal Illness, NAHAT, 1991; EL (95) 22, NHS Executive 4. 23 February 1995; and Specialist Palliative Care: A Statement of Definitions, NCHSPCS, 1995).

(II) Decisions concerning CPR policy for individual patients should be clearly recorded and communicated to all relevant 5. staff, including deputising or GP cooperative services.

(III) It would be helpful if ambulance service providers could be made aware of the policy relating to individual patients who would not benefit from, or wish for, CPR. Local mechanisms for the communication of anticipatory decisions to paramedical staff in relation to individual patients in the domiciliary setting would also be helpful.

References 1. Dautzenberg RL.J, Broekman T.C.J, Hooyer C, Schonwetter R.S, Duursma S.A. Review: Patient-related predictors of cardiopulmonary resuscitation of hospitalised patients, Age and Aging 1993: 22. 464-475. 2, Bedell S.E, Delbanco T.L, Cook EY, Epstein F.H. Survival after cardiopulmonary resucitation in the hospital, N Engl J Med 1983:309:569-575. 4. Ebell M.H. Pre-arrest predictors of survival following in-hospital cardiopulmonary resuscitation; comparison of two predictive instruments, Resuscitation 1994: 28: 21-25. 5. British Medical Association and Royal College of Nursing. Decisions relating to cardiopulmonary resuscitation. Joint statement in association with the Resuscitation Council (M, BMA House, London, March 1993. Sommerville A. Cessation of treatment, non-resuscitation, aiding suicide and euthanasia. In: Fisher F. Medical Ethics Today: Its practice and philosophy, London BMJ Publishing Group, 1993: 173. 6. Murphy D.J, Burrows D, Santilli S et al. The influence of the probability of survival on patients preferences regarding cardiopulmonary resuscitation, N Engl J Med 1994:330:545-549. 7. Miller D.L, Gorbien MA Simbartl LA, Jahnigen D.W. Factors influencing physicians in recommending in-hospital cardiopulmonary resuscitation, Arch Intern Med 1993: 153: 1999-2003. 8. George A-L, Folk BY, Crecelius PL, Campbell W.B. Pre-arrest morbidity and other correlates of survival after in-hospital cardiopulmonary arrest, Am J Med 1989: 87: 28-34.

JOINT WORKING PARTY BETWEEN THE NATIONAL COUNCIL FOR HOSPICE AND SPECIALIST PALLIATIVE CARE SERVICES AND THE ETHICS COMMITTEE OF THE ASSOCIATION FOR PALLIATIVE MEDICINE OF GREAT BRITAIN AND IRELAND

Mrs B Biswas, Matron, LOROS, Leicestershire Hospice, Leicester Dr K Dunphy, Macmillan Consultant in Palliative Medicine, Macmillan Runcie Day Hospice, St Albans. Dr J Ellershaw, Medical Director, Marie Curie Centre, Liverpool Dr M Minton, Consultant in Palliative Medicine, Sir Michael Sobell House Palliative Care Unit, The Oxford Radcliffe Hospital. Mr D Oliviere, Macmillan Lecturer in Social Work and Palliative Care, School of Social Work and Health Sciences, Middlesex University, Enfield Mr D Praill, Chief Executive, Help the Hospices, London Dr F Randall, Consultant in Palliative Medicine, Macmillan Unit, Christchurch Hospital, Dorset Dr G Rathbone, Consultant in Palliative Medicine, LORDS, Leicestershire Hospice, Leicester Dr T Tate,- Consultant in Palliative Medicine, The Margaret Centre, Whipps Cross Hospital; Consultant in Palliative Medicine, St BartholomeVs Hospital, London

National Council for Hospice and Specialist Palliative Care Services Heron House, 322 High Holborn London WCIV 7PW Tel: 0171-269 4550 Fax 0171-269 4548 A Company limited by guarantee number 2644430 Registered Charity No 100567 1

National Council for Hospice and Specialist Palliative Care Services
VOLUNTARY EUTHANASIA: The Council's View

Adopted by Council on 17th July 1997

Introduction

The National Council for Hospice and Specialist Palliative Care Services is the representative and coordinating multiprofessional body for those providing hospice and specialist palliative care services in England, Wales and Northern Ireland.

This document represents the view of Council on voluntary euthanasia which may be defined as direct killing of patients at their own request to prevent further suffering.

Hospice and specialist palliative care services aim to promote comprehensive care for those with progressive advanced disease and a short life expectancy in order to maximise the quality of life remaining, enabling patients 'to live until they die' and includes psycho-social care as well as adequate pain and symptom management. Such provision also recognises and aims to meet the needs of relatives and carers through professional advice and support for the close family and friends of the patient.

Council endorses the conclusions of the House of Lords Select Committee on Medical Ethics (1994).(1) This document elaborates upon some of those conclusions, reproduced here in bold.

1. The principles of palliative care affirm life whilst regarding death as a natural process to be viewed neither with fear nor a sense of failure. Death may be impossible to postpone but should not be hastened. Respect for the dignity of the individual is important, and regarded by many as paramount. Such respect is not manifest in the act of killing the patient which would merely serve to confirm the individual's falsely devalued sense of self-worth.

"We recommend that there should be no change in the law to permit euthanasia (para. 237)". (para. 278).

2. Those arguing for the legalisation of euthanasia point to a feeling of powerlessness that many patients experience in their relationships with their doctors. Yet the legal right of patients to reject treatment is well established. Patients should be reassured, and left in no doubt that they cannot be subjected to life-prolonging procedures against their will.

Some people fear that whilst they remain reasonably well they will be able to adequately express their wishes regarding treatment, but that, with increasing debility, they may lose this power and with it the ability to exercise control over their continuing medical care. Palliative care involves a partnership between patient and professional in which the professional seeks to establish the evolving care wishes of the patient within an emotional environment of honesty, openness and trust. With care such as this the patient should have no doubt that, should they become unable to express their wishes, their further medical management will continue to reflect their previously expressed sentiments. Written advance directives are a more formalised way of achieving the same result, despite their lack of statutory basis. However, case law in this country leaves little doubt that an informed, competent, applicable and voluntary refusal of treatment is legally binding on the doctor. Council welcomes this.

"We strongly endorse the right of the competent patient to refuse consent to any medical treatment (para. 234)".(para 279)

"We commend the development of advance directives, but conclude that legislation for advance directives generally is unnecessary (paras. 263, 264)". (para 296)

3. Some doctors and carers experience difficulty in what they perceive as a choice between leaving the patient at a safe dose of analgesic but in discomfort on the one hand and giving an 'overdose’deliberately precipitating death on the other. The choice is largely an illusion. The occasional need for high doses of analgesics and other drugs in the final stages of life can cause anguish among doctors and care-givers alike and lead to the perennial misinterpretation by the media and the public of this as euthanasia by stealth. The dosage required by one patient may be hundreds of times greater than that required by another, affording comfort to that individual without compromising the level of consciousness or lucidity.2 Even if, however, 1.Report of the Select Committee on Medical Ethics (1993-94)HL 21-1 2~(a) Plasma Concentrations and Renal Clearance of Morphine; Morphine - 3 Glucuronide and Morphine 6 Glucuronide in Cancer Patients Receiving Morphine. Clin Phamacokinet, Somogyi AA et al, 1993; 24(5); 413-20 (b) Analgesic Use in Home Hospice Cancer Patients. McCormack A et al. J Fam Pract 1992; 34(2); 160-4 c Control of Severe Pain in Children with Terminal Malignancy. J Pediatr, Collins JT et al, 1995; 126(4): 653-7 there is some real risk of shortening life, the reasonable and responsible doctor will not shirk from adequate symptom control. This is legally sound and ethically defensible through the principle of double effect. The principle asserts that if a good effect is achievable only at the risk of producing a bad effect, this is permissible provided the intention is solely to produce the good effect. Doctors already have all the latitude they require in legal terms to ensure that patients do not die in pain.

"Double effect is not in our view a reason for withholding treatment that would give relief, as long as the doctor acts in accordance with responsible medical practice with the objective of relieving pain or distress, and without the intention to kill (para. 242)".(para. 282)

4. Council believes that the widespread and equitable availability of specialist and other palliative care services will do much to minimise rational and persistent requests for euthanasia. The wider availability of palliative care services would be an expression of society's humanitarian concern for people who are dependent, disabled or dying.

"We strongly commend the development and growth of palliative care services in hospices, in hospitals and in the community (para. 241)" (para. 281)

However, universal availability of excellent palliative care services will not and can never eliminate all such rational and persistent requests for euthanasia. For those few who would make persistent and rational requests for euthanasia despite the availability of high quality palliative care, the provision of such care may seem to have no relevance. For them, the debate has moved beyond the practicalities and limitations of any medical or psychosocial management.

In these circumstances the law should reflect the respective moral weights given to the claims of the person who wishes to die on the one hand and the wider interests of society on the other. Council believes that to legalise euthanasia will risk undermining the freedoms of the majority of society in an attempt to promote the autonomy of the small minority of patients who might retain an interest in ending their lives in this way. This risk to society arises from the potential for abuse of legalised euthanasia by, for example, increasing the pressure (real or imagined) that legalised euthanasia might place on vulnerable people and by the denial of value of elderly, chronically infim, and dependent people. Council believes these risks to be real, Even if we could be convinced otherwise, ethical problems in the direct killing of patients would persist. We acknowledge that maintaining a legal prohibition on the practice of euthanasia exacts a high price on some individuals who may feel that their autonomy has been unacceptably com-promised. In these circumstances, health professionals should acknowledge and respect the values and wishes of such patients uncritically, aiming to enhance personal autonomy and sense of self-worth, and instituting no treatment or aspect of care without the active involvement of competent patients and with their duly informed consent. The arguments advanced indicate that respect for individual autonomy cannot be an absolute value. Regard for the dignity of the individual cannot require health professionals to respect autonomy to the extent of honouring requests for euthanasia, nor can it ignore the potential adverse effect on health professionals or society in general.

Council reaffirms that the intention of good palliative care for dying patients is to relieve their physical, emotional, social and spiritual suffering in the context of respect for their individuality, and without intent to shorten life.

Council believes there is no place for the direct killing of patients at their own request.

"Rejection of euthanasia as an option for the individual entails a compelling social responsibility to care adequately for those who are elderly, dying or disabled (para. 276)". (para. 287)

Useful Reading:

Report of the Select Committee on Medical Ethics, Volume 1 - Report, House of Lords (1993-94) (HL Paper 214) Advance Statements about Medical neatment -available from the British Medical Association, Tavistock Square, London, WC1H 9JP at 6.95 pounds. Advance Statements about Future Medical Treatment : A Guide for Patients - available from the Patients Association, 8 Guilford Street, London, WC1N 1DT at 3 pounds.

MEMBERSHIP OF COUNCIL'S WORKING PARTY ON ETHICS:

Dr Teresa Tate, (Chairman), Consultant in Palliative Medicine, The Margaret Centre, Whipps Cross Hospital Consultant in Palliative Medicine, St Bartholomew's Hospital, London Mrs Bronwen Biswas, Matron, LOROS, Leicestershire Hospice, Ioeicester Mrs Jo Bray, Occupational Therapists Specialist Section HOPE Mr Michael Connolly, Macmillan Palliative Care Nurse, Wythenshawe Hospital, Manchester Dr Kilian Dunphy, Macmillan Consultant in Palliative Medicine, West Herts Community Health NHS Trust, St Albans. Dr Bobbie Farsides, Centre of Medical Law and Ethics, King's College London (co-opted) Dr Rob George, Senior Lecturer Palliative Medicine, Palliative Care Centre, U.C.L. Medical School Ms Pam McClinton, Clinical Development Adviser, South Bedfordshire Community Healthcare Trust Mr David Oliviere, Macmillan Lecturer in Social Work and Palliative Care, School of Social Work and Health Sciences, Middlesex University, Enfield Mr David Praill, Chief Executive, Help the Hospices, London THE NATIONAL COUNCIL Honorary President: Honorary Vice Presidents; Chairman Vice-Chairmen: Honorary Treasurer: National Cancer Charities Macmillan Cancer Relief Help the Hospices Marie Curie Cancer Care Sue Ryder Foundation NHS Hospices and Teams! Representative Professional Organisations Association for Hospice Management Association of Hospice and Specialist Palliative Care Social Workers Association for Palliative Medicine of Great Britain and Ireland RCN Nurses Managing Hospices/Specialist Palliative Care Services RCN Palliative Nursing Forum Forum of Chairmen of Independent Hospices Dame Cicely Saunders OM DBE FRCP Professor Eric Wilkes OBE Sir Robert Evans CBE FEng Norman Blacker Dr Derek Doyle OBE Nicholas Young John Overton FCA Regional Representatives Sixteen regional representatives, elected by hospices and home cire teams, both voluntary and NHS, in the health regions in England, Wales and Northern Ireland. Observers Scottish Partnership Agency for Palliative and Cancer Care Department of Health ACT (Association for Children with life-threatening or Terminal conditions and their families) Executive Director Mrs Jean Gaffin OBE