Voluntary euthanasia (VE) is a special case of suicide, sometimes called "physician-assisted suicide" since, usually, the person is terminally ill and needs assistance in ending his or her life: although this may be given by a close friend or in some cases relative, rather than a doctor. The conventional suicide is, typically, not terminally ill and can terminate his/her life without assistance.

There is a long debate on the rights and wrongs of suicide going back at least to Plato but VE has recently become very topical, especially in the UK where there are currently two bills going through Parliament. Firstly a Government-sponsored Mental Capacity bill is concerned with all problems of incapacity and so only marginally with VE. And secondly a private member's bill introduced in the House of Lords by Lord Joffe called the Assisted Dying for the Terminally Ill bill, which after its second reading in March was referred to a committee of the House of Lords where it is at time of writing. Of these the first is in my view likely to reach the statute book; the second probably will not, much as I would like it to. The usual, mainly religious, opponents have attacked both bills.

The current topicality is matched by an explosion of medical and legal academic literature on VE, which started about 30 years ago with high-profile cases in the USA (Quinlan and Cruzan). Recent trends, which have sharpened the debate, are both a decline of mainstream religion and the rise of human rights movements. Also medical technology which prolongs life and the consumerisation of health care have appeared. These trends though apply only in the "developed" world.

Details of some relevant cases are worth considering from several angles - patient autonomy, best interests and dignity. How would you wish yourself, or someone on whose behalf you had to form a judgement, to be treated in such a situation? What conditions, if any, would you regard as not allowing you to continue living a life worth living?

Today (30 September) a High Court judge was due to decide the fate of an 11-month old premature baby girl whose parents wanted to continue life-prolonging treatment, whereas doctors wished to discontinue treatment on grounds of medical futility. What are the best interests of the patient here?¹ In other cases, such as Creedon (UK 1995), a baby boy born with severe brain damage, no sight or hearing, the parents sought permission to have him sedated and die, whereas the doctors refused this: the baby died before the case could come to court.

More typical of VE is the case of "Miss B.", a woman of 42 who was paralysed but mentally unimpaired. She had a living will, see below, expressing her wish not to receive life-prolonging treatment if she suffered permanent unconsciousness. Medical staff recognised her mental capacity but refused to carry out her wishes. In the High Court in 2002 Dame Butler-Sloss held that continuation of artificial ventilation was against Miss B.'s wishes and therefore amounted to trespass. She even awarded nominal damages against the hospital.

Three cases involve patients in a persistent vegetative state (PVS). For Karen Ann Quinlan (USA, 1976) the patient's father's wish to withdraw treatment was upheld by the court as a substituted judgment. This, a US legal term, is not recognised in UK law so far as I know but means that a person close to the patient whose wishes are not known in a formal sense (who had not made a formal living will) may make a judgment on the patient's behalf, based on their knowledge of the patient's personality and values. Alternatively, a judgement based on the best interests criterion may have been accepted by the court.

Similarly the parents of PVS patient Nancy Cruzan (USA, 1990) sought to discontinue her treatment but this was refused by both a Missouri court and the Supreme Court, on the grounds that she had not executed a living will. The case went back to Missouri where eventually the court accepted that there was, after all, sufficient evidence of the patient's wishes for treatment to be discontinued, and this was done after seven years of PVS.

The first such British case is that of Tony Bland (UK, 1993), who was caught up in the Hillsborough stadium disaster of 1989 and fell into a PVS. When the parents sought leave to discontinue treatment, this was granted on the best interests criterion. "The futility of the treatment justifies its termination." - Lord Goff.

Regarding conflict of the principles of sanctity of life versus self-determination: "There must be an ... accommodation between principles, both of which seem rational and good, but which have come into conflict with each other." (Hoffmann LJ in the Bland case, see above.)

Ronald Dworkin (Life's dominion, 1993²) argues that both opponents and defenders of abortion recognise the intrinsic value of life, since they both agree that a late abortion is morally more serious than an early one. Dworkin calls this a "detached" or impersonal value, since it goes beyond the value of any individual life. He also calls it "essentially religious", which enables him to argue that abortion is therefore a private matter which should not be subject to unwarranted intrusion by the State, in accordance with the First Amendment. But by "religious" he means no more than that such a belief occupies an analogous position in an atheist's value system to a religious belief in a religious believer's value system. Belief in the intrinsic value of human life is used by opponents of abortion and VE to construct a conservative (prohibitive) view of the issue; but can equally well be used to support a liberal (permissive) view, with the aid of concepts such as the dignity and quality of life. Dworkin also makes a useful distinction between "experiential" and "critical" interests: the former are important to people's enjoyment of life, but are largely matters of taste - such as watching football or listening to Mozart. Whereas critical interests are central to life such as loss of sight, loss of employment, breakdown of marriage etcetera. Elsewhere in his book Dworkin makes a similar distinction between "incremental" values - the more the better - and "inviolable" values such as the value of life, which are clearly not incremental. Judges, Dworkin suggests, have tended in the past to talk as if it were only experiential interests that count.

One argument used by opponents of VE which I think deserves to be taken seriously is that legalising VE would lead to undue pressure on the terminally ill in order to keep health costs down. Against this it can be argued that the terminally ill are not the ones who need expensive life-support: what they need is palliative care at the end of life. Sissela Bok has argued against legalising VE in the US and other countries with no universal health care system (in the US some 40M people lack even minimal health care coverage): this has some force, but not so much as to weigh against the cases of patients in unbearable pain.

Slippery-slope arguments are sometimes used against VE, often with allusion to the Nazis' extermination programme: but the Nazis did not start with VE and then move on to extermination. Also, slippery-slope arguments should show detailed stages which their proponents usually fail to give.

The Chicago lawyer Luis Kutner started living wills (Advance Directives is the more formal term) in the 1970s. In the US living wills evolved to more individualised forms and almost all US states have by now adopted legislation to recognise living wills and health-care proxies. Some forms of living will are recognised, and appropriate forms distributed, by the Catholic Church. In the UK living wills are nowadays recognised in common law and the basic conditions for their binding force were given by L.J.Donaldson. We none of us know the circumstances in which our lives will end. In the last analysis we are dependent on clinical judgment, based on we hope long years of experience, as to what stage we have reached towards that end. We can at least make our wishes known in advance.

KCR

A discussant mentioned that he himself had made a living will without any feeling of sadness on the subject, rather to the contrary. Another (myself, R.C.) quoted experience in primary medical care that, as a monthly event approximately, where plans to end life surface they are regarded as the second stage of seriousness - the first being suicidal thoughts - in a diagnosis of depression. His suggestion was that such significantly more frequent occurrence calls for full consideration in the context of Voluntary Euthanasia - at the request stage preferably.          (R.C.)

¹ The judge (on 7 October) decided in favour of the doctors.
² See article below.

KCR

... PIZARRO'S CAPTURE of Atahuallpa illustrates the set of proximate factors that resulted in Europeans' colonizing the New World instead of Native Americans' colonizing Europe. Immediate reasons for Pizarro's success included military technology based on guns, steel weapons, and horses; infectious diseases endemic in Eurasia; European maritime technology; the centralized political organization of European states; and writing. The title of this book will serve as shorthand for those proximate factors, which also enabled modern Europeans to conquer peoples of other continents. Long before anyone began manufacturing guns and steel, others of those same factors had led to the expansions of some non-European peoples ...

But we are still left with the fundamental question why all those immediate advantages came to lie more with Europe than with the New World. Why weren't the Incas the ones to invent guns and steel swords, to be mounted on animals as fearsome as horses, to bear diseases to which European lacked resistance, to develop oceangoing ships and advanced political organization, and to be able to draw on the experience of thousands of years of written history? Those are no longer the questions of proximate causation ... but questions of ultimate causation ...

Although the above quotation gives away the punch line of the book, there is a mass of crucial detail too - amounting to a standard text of Human History as Science. Conventional history starts with the discovery of writing around 3.000 YA (years ago) but human history starts at a date variously set at points between 200,000 YA and 50,000 YA according to the theory you hold on the crucial difference between mankind and his primate ancestors. Fortunately for us in Europe it is 40,000 YA with only limited disagreement since we are migrants from Africa of that vintage. Professor Diamond has set his onset at 13,000 YA, a reasonable compromise. Professor Steven Mithen, in a somewhat similar popular compendium "After The Ice" (reviewed in EHA Bulletin 64) has set his at 20,000 BC. "Guns, Germs and Steel", though, has the edge in terms of its record of significant facts, especially post-5,000 BC when prehistory ceases.

RC

We record (belatedly) with sadness the death of John Rudge, at the age of about 70, earlier this year.
John was the son of a chemistry teacher, and himself took a science degree. He was an active member of Hillingdon Natural History Society, as well as of EHA, and gave us one or two presentations on astronomy and other scientific subjects where his knowledge was considerable. Readers of NewScientist will have noticed occasional letters from him. His career took him to EMI in Hayes, but when the research department was closed down, director and all, in the 1970s John never again found satisfactory employment for his obvious gifts. My own impression of him was of a man who, following a different path, might have made a fine teacher. As it is, those who knew him will remember a man who made a pointed and knowledgeable contribution to our meetings, and, not least, a humanist.

Charles Rudd

•John Rudge and Richard Hall. We started with sad thoughts of funerals and obituaries (see above, and in Bulletin 68).

•Subjectivity. Maggie's poem "The curtains are missing....there is NOTHING to be afraid of" was read as an introduction to the topic but discussion was deferred until a future occasion.

•Willful ambivalence expressed as an alternation between subjective and objective modes of thought was according to Raymond Carlisle a frequent cause of soluble problems. Thoughts about instant gratification followed. Are the suicide-bombers mentally ill? They are not depressed, but high up on the DSM scale of personality disorder said John Bennett. No longer is any clear distinction made between sane and mad, such as there was years ago, added Raymond - who in the past had discussed the question of purported GPI (brain syphilis) with two of Idi Amin's doctors.

•Terrorism. Why was restoring (creating?) democracy in Iraq not like Germany and Japan after WW2? Martyrdom has extended itself from the suicide bombers. K.B. a British engineer went out to help the Iraqi people, or just went to various parts of the world, wherever he could make some money exercising his skills.

•"Britain AD", is the title of current TV programmes by Francis Pryor, who holds the lights did not go out when the Roman legions left Britain in 410 CE. Nice to think of trade with the Byzantine Empire in the time of Justinian (about 520 CE), ceramics for Cornish tin (re excavations at Tintagel). Which at least goes to show that we don't always, as some claim we do, end up talking about God.

KCR