05 February 2010

Pillows, morphine and autonomy

The backlash against the absurdities of the socialist project will be authoritarian, I suggested in the previous post. Support of the underclass produces too many children without adequate parental care? Response: selective sterilisation. What about the fact that a system of free medical ‘care’ (of sorts) results in a vast army of the elderly who need to be supported to live on into decades of decrepitude? Here the answer is equally simple: euthanasia. Voluntary, involuntary, socially expected, whatever. In practice the boundaries between the different types are too blurred for most people to bother much about the distinctions.

It is interesting how euthanasia is usually presented in terms of liberty, choice, autonomy: the supposed right to determine your destiny. Martin Amis for example — a writer who was once as fashionable* as James Joyce, and about as readable, and who now seems to have turned into a social oracle for the nation — has warned of a coming silver tsunami, and asserts that “a way out for rational people” should be available and “quite easy”. His practical suggestion (not clear how flippantly meant) is to have euthanasia booths on every corner. In spite of the consumerist image which this conjures up, Amis’s motivation seems to have more to do with disgust than with concern for autonomy.

How is society going to support this silver tsunami? There’ll be a population of demented very old people, like an invasion of terrible immigrants, stinking out the restaurants and cafes and shops.
Terry Pratchett, a man with fewer literary pretensions but more popular support, also thinks euthanasia should be easier, but seems similarly ambiguous about the autonomy issue. His article last year for the Mail on Sunday is typical of many euthanasists in that it reveals what is either confusion, or indifference, about the importance of the voluntary-involuntary distinction. Pratchett starts by explaining his apparent dislike of the term ‘suicide’ and his approval of ‘mercy killing’, and goes on to give examples of the latter.
As a young journalist I once listened in awe as a 90-year-old former nurse told me how she helped a dying cancer patient into the great beyond with the help of a pillow. In the absence of any better medication at that time and place, and with his wife in hysterics at the pain he was forced to endure, death was going to be a friend; it was life, life gone wild, that was killing him. ‘We called it “pointing them to Heaven”,’ she told me.

Decades later, I mentioned this to another, younger nurse, who gave me a blank look, and then said: ‘We used to call it “showing them the way”’. Then she walked off quickly, aware that she had left a hostage to fortune.
Pratchett says nothing to suggest he has a problem with such practices, and gives no indication that the patients in question had requested the pillow treatment, or its contemporary equivalent (typically, excess morphine).

Both authors, along with the euthanasia lobby in general, seem to think that it should be possible to have tests, controls, checks, to ensure that the wrong people do not choose this way out. But there is really only one course that would promote genuine autonomy: make suicide pills freely available. Anything involving checks and controls exercised by others risks being as unfree and coercive as conventional medicine currently is.

The current Scottish End of Life Assistance Bill shows what ideas about ‘rational’ suicide being made ‘easy’ are likely to mean in practice. According to this Bill, to get the lethal drug, or (more likely) to get someone to administer it to you, you would have to:
(1) be diagnosed as “terminally ill”, or as “permanently physically incapacitated” to the extent that you cannot live independently;
(2) make two successive formal requests to a doctor, who would have to be sympathetic to the idea of assisted suicide to begin with;
(3) the doctor would have to meet you both times to discuss your decision, agree to the precise means (in practice, decide** the precise means), and to consider whether you are acting under ‘undue influence’;
(4) a psychiatrist would after each of the two occasions also have to meet you, to determine whether (in his opinion) you are suffering from any mental disorder;
(5) each of the requests to the doctor must have signatures from two witnesses (not doctor or psychiatrist) certifying that
(a) you understand the nature of the request,
(b) you are making the request voluntarily,
(c) you are not acting under any undue influence;
(6) neither doctor, psychiatrist nor witnesses may be relatives (down to great-nieces, including of half-blood), even if they do not stand to inherit.

So assuming you are terminally ill and suffering extreme discomfort, at least four people not related to you would have to be persuaded to take the risk of being held partially responsible for you killing yourself, and would have to actually be motivated in the first place to let you have what you want.

* * * * *

At present individuals who do something as innocuous as accompany a relative to an overseas suicide clinic are at risk of criminal proceedings under the Suicide Act. The current indication by the state that it would not prosecute in such cases is not really adequate protection. The Suicide Act should simply be abolished. Providing people with the means should not be a crime.

Active killing is another matter entirely. Would it count as murder to hand an individual a pill which he knows will kill him if swallowed? No, so decriminalise this act altogether. Would it normally count as murder to inject him with a drug that kills him? — yes — and is his consent an adequate defense? — no. So do not decriminalise that act. It should not be beyond the means of the pharma industry to develop a painless suicide method that is easily self-administered. Perhaps even one where, if you change your mind with one minute to go, you can take an antidote which would save you, though leave you feeling extremely ill for 24 hours.

So: make suicide drugs available without restriction, and decriminalise the act of providing them, but not the act of administering them. Simple, isn’t it. Oh, but the terrible abuses and other consequences which would ensue, the cry goes. You may regard some of them as undesirable. But what is going on now, and what will certainly go on more and more in the face of the “silver tsunami” taking up residence in state homes and NHS beds is worse, though less visible. (Hence, from some people’s point of view, conveniently out of sight and therefore preferable.)

Law professor Margaret Brazier’s book on medical law cites a case in which a woman
was found guilty of trying to persuade her 89-year-old mother in a nursing home to kill herself so that she could inherit her estate. A secret camera installed by the police showed the daughter handing her mother drugs concealed in a packet of sweets, and pinning a note on her dress saying ‘Don’t bungle it’! ***
I suggest this kind of thing is trivial by comparison with what would come to light if one were able to investigate the facts behind the large number of deaths currently hastened or otherwise brought about by medical staff. Of course, unlike where relatives are involved, it would be difficult to establish the facts in such cases. In a medical context, a role in killing is often hard to distinguish from a role in routine care, quite apart from the culture of secrecy which exists within the medical profession.

The idea that within a modern monopolised and state-dominated medical system there are not motives for killing as potent as those of potential inheritance is unrealistic. It may not involve personal gain in the conventional sense, but when dealing with a sick elderly person in one’s power, constituting a drain on available resources, one does not need to inherit to have an interest in their early demise. If they are neither friend nor relative, the psychological inhibitions against killing are likely to be lower not greater. Such motives are all the more potent for being spuriously legitimised by an ideology which demands that holders of power should allow considerations of ‘social justice’ to override the wishes of individuals.

Terry Pratchett writes about little old ladies who told him “I’ve been saving up my pills for the end, dear”. He adds,
I have met retired nurses who have made their own provisions for the future with rather more knowledgeable deliberation.
Very sensible, but why should this solution be available only to medical staff? If they are allowed to buy themselves a feeling of control, as Pratchett puts it, then let everyone else do the same. I am sure nurses don’t have a monopoly on good sense. Do not make such purchases of control dependent on the agreement or actions of outsiders. In many cases, a sense of control is what it is all about. Many would decide not to exercise it when it comes to it, but feel better for having had the choice.

Short of dismantling the current medical and psychiatric professions and starting them again from scratch as free-market versions, any solution that involves their participation would be potentially coercive, and therefore liable to make things worse not better for the elderly and terminally ill.

If my suggestions seem extreme, this may be because they are not ones given space by the ‘bioethics’ literature coming out of state-funded universities which influences the way these issues are treated by the media. This literature tends to be firmly on the side of collective decision-making and highly deferential to the views of the medical profession. Extremity per se is not however the issue. Statist academia seems perfectly willing to make room for other extreme views — killing handicapped infants, removing organs without consent, denying life-saving treatments — provided they are compatible with interventionist-egalitarian ideology.

The above is a brief treatment of a complex topic. A more detailed analysis is available in The Power of Life or Death. More up-to-date research on the topic could be produced if Oxford Forum were provided with adequate funding to do so. This should be done, if only to create a more balanced body of academic opinion, which at present is severely biased in a pro-state and anti-individual direction.

* The Sunday Times, whose interview with Amis elicited the comments on euthanasia, at one point enquires of him whether he “would boff someone unattractive”. Good old Times, always ready with the profound cultural probings.
** Most people who visit their doctor with a clear idea of what they want seem to end up getting something else — what the doctor wants.
*** Medicine, Patients and the Law, second edition, p. 448