Tuesday 30 November 2010

The vast majority of the members of Lord Falconer’s new commission on assisted dying are well-known names in the pro-legalisation lobby

Today I went by invitation to the launch of Lord Falconer’s Commission on ‘Assisted Dying’ at the London headquarters of think-tank Demos.

He confirmed that the commission has been set up with funding provided by Bernard Lewis and celebrity novelist Terry Pratchett (pictured), a Patron of Dignity in Dying and advocate of legalizing assisted suicide for people with dementia. He also confirmed that Dignity in Dying itself (formerly the Voluntary Euthanasia Society) had made the arrangements for its formation.

He insisted however that his inquiry into assisted dying in the UK would be ‘an objective, dispassionate and authoritative analysis of the issues’.

The aims of the commission are to consider ‘what system, if any, should exist to allow people to be helped to die and whether changes in the law should be introduced’. He confirmed at the meeting, in answer to a question, that the commission would deal only with assisted suicide and not with euthanasia.

In an attempt to answer critics (including me) who have raised concerns over the commission's transparency, independence and objectivity, he said: ‘We will evaluate all the evidence we hear on a fair basis, judge us at the end by the quality of our report.’

Today we learnt the names of all twelve members of the commission. It was no surprise to learn that the majority (nine) are known already by those who work in this field to support a change in the law to allow assisted suicide. Most have actively worked towards this end in the past. None of the remaining three are known to oppose it.

I asked the Demos Director about how the members of the commission were selected and she confirmed that they had been effectively handpicked by Lord Falconer himself. She didn't go as far as saying they had been interviewed by DID CEO Sarah Wootton and Terry Pratchett himself (and I didn't ask), but that might be a good line of questioning for journalists.

Falconer has included people who are prominent in their respective professions and have impressive sounding titles that bring a degree of gravitas to the proceedings but he has kept very quiet about their personal views. This will effectively fool most casual observers and media people not that familiar with the broader cast in this whole debate.

He has, for the same reason, avoided using any of DID's official patrons, seemingly in order to create the impression that this is a group of 'independent' people not linked with DID (when in fact most of them are), or who at very least, in the main, share Falconer's own views.

So who are the twelve members of this grand jury?

All four Parliamentarians on the commission have either made their pro-assisted dying views public or voted for legalisation in the Houses of Parliament.

Lord Falconer himself, who will chair the commission, has campaigned long and hard on this issue and attempted to legalise assisted suicide via an amendment to the Coroners and Justice Bill in 2009.

Baroness Elaine Murphy of Aldgate and Baroness Young of Old Scone share Falconer’s views – Young supporting Falconer’s amendment on 7 July 2009 and Murphy voting for Lord Joffe’s Assisted Dying Bill on 12 May 2006. Penny Mordaunt MP has not had an opportunity to vote on the issue but recently made her own support for legalisation very clear.

While all the major disability rights organisations in the UK (RADAR, UKDPC, NCIL, SCOPE, Not Dead Yet) oppose a change in the law Stephen Duckworth, Chief Executive of Disability Matters Limited, is one of those rare disabled people actually to back legalisation. 'Disability Matters' sounds grandiose but it is in reality just a private business - and judging by the current accessibility of its website, may not be doing that much at present. Duckworth happens to be disabled (hence his usefulness to Falconer) but he seems not to represent anyone but himself. Hardly surprising then that he is included on this panel.

Whilst 95% of Palliative Medicine Specialists are opposed to a change in the law Lord Falconer has managed again to find two who buck that trend in Professor Sam Ahmedzai, Professor of Palliative Medicine in Sheffield, and Dr Carole Dacombe, Medical Director, St Peter’s Hospice.

Earlier this year I was involved in a two hour dialogue in Oxford (over dinner) with Lord Ian Blair of Boughton, former Commissioner of the Metropolitan Police, and I can assure you that he too firmly supports a change in the law.

Sir Graeme Catto, former President of the General Medical Council, recently spoke in support of the new organisation seeking to promote the legalisation of ‘assisted dying’, Health Professionals for Change.

So who does that leave? Just three whose views we (or at least I) do not already know but may be able to guess: Dame Denise Platt, Member of the Committee on Standards in Public Life; Celia Grandison-Markey, Management Consultant for Health and Social Care in the public sector; and the Revd Canon Dr James Woodward, Anglican Priest and Canon of St George’s Chapel, Windsor.

Any information of any of these would incidentally be most welcome.

So is this an independent committee? I think not! In fact I am astounded that Demos, which is to act as secretariat, providing administrative and research support, has agreed to work with such an unbalanced group.

But I suspect that like most of the British Public, Demos was simply not aware of where these illustrious people’s personal convictions lay.

Lord Falconer, of course, is perfectly free to set up an ad hoc committee to take evidence and make recommendations to Parliament. It is a free country and he has every right to try and influence public policy.

But it is a trifle disingenuous of him to pretend that a group with such clearly settled prior convictions, might bring any impartiality or objectivity to bear on these important issues.

Sunday 28 November 2010

Further disclosures about Lord Falconer’s Commission on Assisted Dying raise more questions about transparency and independence

The Commission on 'Assisted Dying', due to be launched on Tuesday 30 November, has attracted some more attention in the press today and we are given additional information about the identities of some of the members of Lord Falconer’s ‘independent’ panel.

The Observer has today run a piece with the intriguing title ‘Assisted Suicide Law to be reviewed by Lords’. This creates the misleading impression that this commission is somehow part of the parliamentary process when it is nothing of the sort.

Instead, as we have already learnt, it is a privately organised enquiry which was the idea of campaign group ‘Dignity in Dying’ (formerly the Voluntary Euthanasia Society) and is being funded by celebrity novelist Terry Pratchett (who like Baroness Warnock backs legalising assisted suicide for people with Alzheimer’s disease).

It is true that the Commission intends to publish a report in October 2011 which it hopes will be discussed in Parliament but we need to be clear that the pro-euthanasia lobby has decided to take this ‘independent’ route because their attempts to legalise assisted suicide through the standard parliamentary processes have failed by large margins at the last two attempts (148-100 and 194-141 in the House of Lords in 2006 and 2009 respectively).

So what do we know thus far of those involved?

As noted previously, Lord Falconer, who attempted to amend the Coroners and Justice Bill in 2009 to decriminalise taking 'loved ones' to Zurich so that they could end their lives at Ludwig Minelli’s suicide facility, will chair the commission.

Another member of this 12-person ‘independent’ team is revealed today to be Penny Mordaunt MP (pictured), who ten days ago laid her cards on the table as a supporter of so-called ‘assisted dying’.

Further members include Baroness Barbara Young, the former chair of the government's health watchdog, Canon James Woodward of St George's Chapel, Windsor and Stephen Duckworth, who has campaigned on disability issues.

Baroness Young of Old Scone supported Lord Falconer’s move to decriminalise assisting with suicide in 2009 and also spoke in support of Lord Joffe's Bill in 2006. So the two ‘Lords’ on the panel who are to review the law are both already committed to legalisation.

Stephen Duckworth also supports 'assisted dying' according to a statement on the DID website and seems to have no link with any of the main disability rights organisations who oppose any change in the law such as RADAR, Not Dead Yet, UKDPC, NCIL or SCOPE.

We wait with interest to see who the other seven members are but it will be even more interesting to learn how they were selected. Were they nominated or appointed and if so by whom? Did they apply to be included and if so how did they learn about the commission’s existence and what was the selection process? Was there an interview? If so who was on the panel and how ‘independent’ were they?

I do hope that on Tuesday, when the commission is launched there will be full transparency on these questions along with full disclosure about the commission’s funding and any possible financial and ideological vested interests of those selected.

I was interested to read today in the Observer that Lord Falconer felt his 2009 amendment failed because it didn’t contain enough safeguards against abuse. It would be interesting to hear from him more specifically about which safeguards he felt were inadequate and why.

Lord Joffe’s ‘Assisted Dying for the Terminally Ill Bill’ also failed on grounds of inadequate safeguards and serious questions have been raised about whether the key safeguards currently being campaigned by Dignity in Dying are adequate (ie. ‘mentally competent’, ‘terminally ill’, ‘persistent well-informed voluntary request’, ‘suffering unbearably’). In fact whereas Joffe used a definition of 'six months to live' for 'terminally ill', Sarah Wootton, the Chief Executive of Dignity Dying, extends this to twelve months.

Baroness Young's comment on Joffe's Bill in 2006, when she supported it in her speech, is most enlightening in this context. She said, 'The Bill is a very carefully crafted set of proposals. I very much admire the thoughtful way in which the noble Lord, Lord Joffe, has conducted the drafting and his commitment to amend it to best meet the widest possible range of views. It contains multiple safeguards against misuse. It deserves our and, indeed, the Government's support.'

I note that Health Professionals for Change spokesperson Ray Tallis was heavily defeated in a debate on assisted suicide this last week in Liverpool by Lord Alton who simply outlined the deficiencies in so-called safeguards mentioned to date.

I see also that Baroness Finlay, Professor of Palliative Medicine in Cardiff, has now joined John Pring and George Pitcher in expressing misgivings about the independent nature of the commission. She says, ‘I have been told by someone close to this that they are not looking at whether (to legalise ‘assisted dying) but how. It can't be independent?’

I wonder who the ‘someone close to this’ was and what else they said. There are lots of interesting leads here for enquiring journalists to chase.

It’s going to be a fascinating week.

Saturday 27 November 2010

By focussing exclusively on HIV/AIDS, malaria and TB, Western governments and NGOs have neglected other easily treatable and curable diseases

Micah Challenge is a global coalition of Christians holding governments to account for their promise to halve extreme poverty by 2015.

It is establishing a global movement to encourage deeper Christian commitment to the poor, and to speak out to leaders to act with justice and its specific focus is the Millennium Development Goals.

The Millennium Development Goals (MDGs) are eight international development goals that all 192 United Nations member states and at least 23 international organizations have agreed to achieve by the year 2015.

They include eradicating extreme poverty, reducing child mortality rates, fighting disease epidemics such as AIDS, and developing a global partnership for development.

The aim of the MDGs is to encourage development by improving social and economic conditions in the world's poorest countries.

The eight MDGs were developed out of the eight chapters of the United Nations Millennium Declaration, signed in September 2000. There are eight goals with 21 targets, and a series of measurable indicators for each target.

Goal 6 is to ‘Combat HIV/AIDS, malaria, and other diseases’ and its three associated targets are as follows:

Target 6A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS
Target 6B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it
Target 6C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases

There are five measurable indicators for target 6C but every single one of them relates to tuberculosis and malaria and none to ‘other diseases’.

So in other words, whilst MDG 6 aims to ‘combat HIV/AIDS, malaria, and other diseases’ the exclusive focus of its associated ‘targets’ and ‘measurable indicators’ is actually HIV/AIDS, malaria and TB. To emphasise the point the United Nations webpage on the MDGs highlights just these three diseases.

The Global Fund to Fight AIDS, Tuberculosis and Malaria is an international financing institution that invests the world’s money to save lives. To date, it has committed US$19.3 billion in 144 countries to support large-scale prevention, treatment and care programs against the three diseases.

It claims as a result, through Global Fund-supported programs, to have saved 5.7 million lives, and put over 2.8 million people on AIDS treatment, 7 million people on anti TUBERCULOSIS treatment, and distributed 122 million insecticide-treated nets for MALARIA prevention.

This is perhaps not at all surprising given the support of wealthy donors and celebrities like Bill and Melinda Gates, Warren Buffet and Carla Bruni. But at the same time virtually no progress has been made on ‘other diseases’. If you don’t identify your target there is little chance of hitting it.

So what are these other diseases? And who is championing their cause?

You, like me, may have missed a series of articles in the Guardian highlighting research that is answering just this question, and giving a platform to the British doctor who has been almost a lone voice in trying to attract the world’s attention to this issue.

In 2005 David Molyneux of the Liverpool School of Tropical Medicine said ‘We urge policy makers and health economists to recognise that although HIV, TB and malaria are the most serious problems facing health planners, other diseases exist that can be addressed at realistic cost with effective interventions. Controlling Africa's neglected diseases is one of the more convincing ways to make poverty history.’

As it seems that no one has listened he has now said it again.

The neglected diseases, which include schistosomiasis, river blindness, ascariasis, elephantiasis and trachoma, affect more than 750 million people and kill at least 500,000 every year.

Treating all of these illnesses with a cocktail of four readily available drugs would cost less than 50 cents (28p) a person a year. Furthermore dealing with the forgotten diseases would reduce susceptibility to malaria and help to make socio-economic improvements for those in poverty, as well as save lives.

Molyneux and his fellow researchers are not saying that we should turn our back on HIV/AIDS, TB and Malaria. Far from it! What he is saying is that they must not be our exclusive focus:

‘We urge policy makers and health economists to recognise that although HIV, TB and malaria are the most serious problems facing health planners, other diseases exist that can be addressed at realistic cost with effective interventions. Controlling Africa's neglected diseases is one of the more convincing ways to make poverty history.’

Reaching everyone in Africa who needed treating would cost $200m a year, a mere fraction of the $15bn a year being spent on malaria, HIV and TB.

However, the plight of these people is being neglected because resources are being monopolised in developing countries by HIV, malaria and TB – even though these diseases infect a much smaller fraction of their populations.

These ‘other diseases’ are being missed because of distorted health policy goals.

‘This is not the fault of pharmaceutical companies,’ says Molyneux. ‘They have made available billions of doses of key drugs. Our problem is that we are not providing the impetus or the means for getting these drugs to disease sufferers. People at policy level think that only malaria, TB and HIV exist in the third world. This is not true. Neglected tropical diseases as a whole – like sleeping sickness or bilharzia – cause more of a burden than these big-name diseases but are being ignored.’

Most major pharmaceutical companies have pledged to provide, at no cost, billions of doses of the drugs needed to combat these diseases. But many G8 governments have failed to provide the means or impetus to get those drugs to the people who need them, a failure which Molyneux says is a major one.

‘If we can't deliver free drugs to poor people, I don't think there is much else we can do in international health’, he said.

Matthew’s Gospel tells (4:23) us that ‘Jesus went throughout Galilee, teaching in their synagogues, proclaiming the good news of the kingdom, and healing every disease and sickness among the people.’

Surely if Jesus himself didn’t focus on just some diseases, but dealt with all, then as his people we must do the same.

I pray that it will not be said of us as a generation of Christian doctors, that whilst making an impact on HIV/AIDS, TB and Malaria we turned a blind eye to ‘other diseases’ like schistosomiasis, river blindness, ascariasis, elephantiasis and trachoma.

The neglected diseases (with numbers affected in sub-Saharan Africa)

Ascariasis Most common human worm infection (173 million)
Schistosomiasis Also called bilharzia. Flatworm infection (166 million)
Elephantiasis Worm infection of lymph system (46 million)
Trachoma Leading infectious cause of preventable blindness (33 million)
River blindness Parasite. Symptoms include eye lesions (18 million)

Thursday 25 November 2010

Serious questions raised about status and independence of new Commission on ‘Assisted Dying’

The British Medical Journal (BMJ) last week ran a story about a new Commission on ‘Assisted Dying’ that is due to launch officially on Tuesday 30 November in London.

Demos, which is hosting the commission, describes itself on its website as ‘a think-tank focused on power and politics’ and gives the following information about the launch

‘Lord Falconer (pictured), Chair of the Commission, will make a keynote speech setting out the aims of the Commission on Assisted Dying and launching a public call for evidence.

Lord Falconer's speech will be followed by a Q&A chaired by Kitty Ussher, Director of Demos. Attendees will have the opportunity to meet members of the Commission and refreshments will be provided.

The Commission will look at the issue of assisted dying. It will consider what system, if any, should exist to allow people to be assisted to die, and whether any changes in the law should be introduced.

The Commission will run from 30 November 2010 to September 2011, with a report launched in October 2011. The Commission will act entirely independently and will be solely responsible for its conclusions.’

The BMJ reports that the commission will consist of twelve people and says that the other eleven include ‘ethicists, doctors, lawyers, and law enforcement professionals’. Their names will not be announced until the commission is launched.

Lord Falconer told the BMJ that the idea came from Dignity in Dying (formerly the Voluntary Euthanasia Society), which raised the money for the commission from the best selling novelist Terry Pratchett, who has Alzheimer’s disease, and from businessman Bernard Lewis.

The fact that an ‘independent’ commission on ‘assisted dying’ is to be chaired by a peer who just last year tried to relax the law on assisted suicide, is being funded by a celebrity novelist who is passionately pushing for a change in the law and was dreamt up by a leading campaign group will certainly raise eyebrows.

The Commission has understandably already attracted international media interest along with critical comment.

Both George Pitcher writing in the Daily Telegraph and and John Pring of the Disability News Service writing for the Federation of Disabled People have raised questions about both its status and independence.

Pring quotes Baroness [Jane] Campbell, a leading disabled campaigner against legalising assisted suicide, who said that at this stage – before the full make-up of the commission was known – it ‘does not look in the least independent’.

She added: ‘Demos may make all the claims of independence it likes, but if the commissioners and funders are heavily weighted towards those who support assisted suicide then the manner with which they will look at the evidence will be seen through this prism.’

Baroness Campbell said she was particularly keen to discover whether the commission would involve ‘knowledgeable disabled people with the experience of severe impairment’.

These are all serious questions which require serious answers. One hopes that these answers will be forthcoming next Tuesday amidst the media hype that will almost certainly accompany the launch.

Wednesday 24 November 2010

Larry Norman's nightmare - No contemporary Christian artist writes lyrics like this

Just found Larry Norman's Nightmare on You Tube - astonishingly prophetic from the 1970s.

I've pasted the lyrics here for you. Enjoy!

last night i had that same old dream it rocked me in my sleep
and left me the impression that the sandman plays for keeps
i dreamed i was in concert on the middle of a cloud
john wayne and billy graham were giving breath mints to the crowd
i fell through a hole in heaven i left the stage for good
and when i landed on the earth i was back in hollywood

the california earthquake it tore the land in half
while san andreas cleared her throat i heard tsunami laugh
the ground began to tremble the land began to sway
and people in the other states they were glad they'd moved away
when suddenly california just floated in the breeze
while every thing that wasn't sank down into the seas

and soon i saw atlantis rumble and rise high
and the great egg of euphrates came down out of the sky
out stepped shirley temple with guy kibbee who was dead
and that communist bill robinson whom shirley called black red
they had a marionette of harpo marx they said it was a inside joke
but when i honked his horn he came alive and these were the words he spoke

"with the continents adrift and the sun about to shift
will the ice caps drown us all or will we burn
we've polluted what we own will we reap what we have sown?
are we headed for the end or can we turn?
we've paved the forest killed the streams
burned the bridges to our dreams
the earth is bursting at the seams
and in pain of childbirth screams
as it gives life to what seems
to either be an age that gleams
or simply lays there dying
if this goes on will life survive how can it
out of the grave oh who will save our planet?"

i said i'm pleased to meet you i always thought you were a scream
he said "had you ever thought of having helen keller in your dreams?"
i said errol flynn dropped by but he tried to steal my girl
then she ran off with ronald colman said something about a new world
now i'm stuck with my own cooking hell i'm lonely can't you see
well he grabbed my leg he said exactly eighty nine words to me
count 'em

"let the proud but dying nation kiss the last generation
it's the year of the pill, age of the gland
we have landed on the moon but we'll clutter that up soon
our sense of freedom's gotten out of hand
we kill our children swap our wives
we've learned to greet a man with knives
we swallow pills in fours and fives
our cities look like crumbling hives
man does not live he just survives
we sleep till he arrives
love is a corpse we sit and watch it harden
we left it oh so long ago the garden"

the strings snapped briskly then went slack the marionette lay dead
while hoover played with the motorcade the body slumped and bled
the man who held the camera disappeared into the crowd
i said the hope of youth, fictitious truth, lays covered in a shroud
then up walked elmo lincoln and he said i beg your pardon
but we left it oh so long ago, the garden

Thomas Sydenham's advice to medical students in 1668 deserves more attention today

Thomas Sydenham, a man of deep Christian faith who many regard as the father of English medicine, said the following in his advice to medical students in 1668:

‘Whoever applies himself to medicine should seriously weigh the following considerations:

First, that he will one day have to render an account to the supreme Judge of the lives of sick persons committed to his care.

Next, whatever skill or knowledge he may, by divine favour, become possessed of, should be devoted above all things to the glory of God and the welfare of the human race.

Thirdly, he must remember that is no mean or ignoble creature that he deals with. We may ascertaining the worth of the human race since for its sake Gods’ only begotten Son became man and thereby ennobled the nature that he took upon him.

Finally the physician should bear in mind that he himself is not exempt from the common lot but is subject to the same laws of mortality and disease as his fellows and he will care for the sick with more diligence and tenderness if he remembers that he himself is their fellow sufferer’.

Death of a tea lady - the unforeseen effects of a bad management decision

When I was a general surgical registrar in Auckland, New Zealand the 'management era' was just beginning. Someone, who I expect had never worn greens and didn't know one end of a retractor from another, was examining the operating theatre budget in some office remote from the front line.

About $15,000 needed to be saved and the deed was done by one stroke in the expenditure column. The theatre tea lady was sacked. The next day a metal and glass substitute arrived and took its place in the corner of the theatre tearoom.

If a committee had studied the theatre environment for a decade in order to determine how to deal the worst blow possible to productivity, morale and efficiency for the minimal possible cost they could not have done better; because in value for money terms the theatre tea lady was the most important staff member in the department.

I expect she graduated into her low-paid, low prestige role in the health service through managing to flunk her school exams and close the door to other possible career paths. Perhaps she chose her path willingly and cheerfully.

Regardless, she loved her job and considered it a privilege and pleasure to be part of the team - and in many ways her fussing, appreciation, smiles and sheer human warmth as she dispensed cake, sandwiches and cups of tea made to personal order were part of the glue that kept morale up.

Despite her low status she had a gift for making everyone feel they were appreciated and valued. And I think that helped us in doing the best possible job. By contrast her sudden unannounced departure without a scrap of consultation just fuelled the resentment.

What the faceless bureaucrats failed to understand is that people perform best when they feel they are recognised and appreciated for the work that they do. The sacking of the tea lady was the first step in a long series of management blunders by people who in Oscar Wilde's words 'knew the price of everything and the value of nothing'.

Little things like clean on-call rooms, after hours meals for hard working staff, rubbish bins you don't have to empty yourself and tea ladies who smile and make you feel important make a huge difference to morale, self-worth and performance.

But you have to rub shoulders with those on the clinical front line to appreciate it. And that takes a special sort of manager - regrettably seen rarely in the administrative corridors of the NHS.

Jesus was that special sort of manager - entering our world at the lowest level, taking the form of servant, and bearing our burdens. We desperately need more of him.

Monday 22 November 2010

Scottish GPs add their voices to those calling for final burial of Scottish ‘End of Life Assistance Bill’. Read final committee conclusions here.

A GROUP of 47 GPs have united in opposition to moves at the Scottish Parliament to legalise assisted suicide. The Scotsman published the letter on Saturday.

On Thursday 25 November the Scottish Parliament will vote on Margo Macdonald’s End of Life Assistance (Scotland) Bill, which if passed will legalise both assisted suicide and voluntary euthanasia for terminally ill and disabled people.

It has been calculated, on the basis of figures obtained from other jurisdictions, that the bill, if passed, would result in over 1,000 Scottish deaths per year.

As reported last week the committee set up to scrutinise the bill has now delivered its report and has recommended overwhelmingly that it be rejected.

The full committee report is available on line but I have reproduced its final conclusions here below.

The final conclusion states, ‘Overall, the majority of the Committee was not persuaded that the case had been made to decriminalise the law of homicide as it applies to assisted suicide and voluntary euthanasia, termed ‘end-of-life assistance’ in the Bill, and, accordingly, does not recommend the general principles of the Bill to the Parliament.’

The committee makes a compelling case for rejecting this bill, which would fail to protect vulnerable people and which has been shown to be full of holes that unscrupulous people could exploit.

The pro-euthanasia lobby will no doubt argue that it is still possible to produce a bill with adequate safeguards to prevent any abuse or any danger to public safety.

After many years that case still has not been made. But one thing is certain. If such a bill does in fact exist, then this most certainly is not it.

This bill has now been placed in its coffin, and the final nails have been hammered in. Now it is time for the burial.

Conclusion and recommendations

256. The Committee recommends that the Parliament take the following findings of the Stage 1 inquiry into account when arriving at a decision on the general principles of the Bill—

• There is no ambiguity in current Scots law in this area – if some people choose to travel to other jurisdictions to commit an assisted suicide or to access voluntary euthanasia, they do so because certain, inherent aspects of those actions are unlawful in Scotland. That the decision of whether to prosecute is separate and subject to the Prosecution Code is part of due process. Any call for clarity is, therefore, spurious.
• Examples from other jurisdictions have been offered as though comparable with the proposal in this Bill. However, there is firstly an important difference in the cultural and legislative contexts of those countries compared with Scotland. Secondly, there is a fundamental difference in the breadth and scope of this Bill.
• The Bill seeks to decriminalise both assisted suicide and voluntary euthanasia under a single definition – it would have been clearer for the two acts to have been dealt with as separate provisions in the Bill.
• An individual’s ‘autonomy’ has been advanced by the member in charge as a central argument in favour of the Bill. The Bill would not, however, accord or establish any rights. Further, although courts have acknowledged the right to respect for a private life, they have also acknowledge that this right may have to be tempered in the interests of wider society. The Bill should be considered, then, in the context of preserving a balance between an individual’s right to exercise autonomy and the interests of society as a whole. Most members of the Committee believe that the wider societal concerns should prevail in the context of the Bill and do not accept the principle of autonomy as argued by the member in charge. One member believes that the interests of the individual should prevail.
• The preservation of an individual’s ‘dignity’ has also been presented as a central argument in favour of the Bill. However, ‘dignity’ is capable of two interpretations. Whilst those in favour of assisted suicide see it as a means of preserving dignity in the terminal stages of life and in the moment of death, those against present an equally compelling argument that a hastened death is undignified by its very hastening and that the key to preserving dignity in the terminal stages of life lies in the quality of care available to and the respect afforded to the dying. It is impossible to reconcile these arguments.
• In Scots law, if a person aged over 16’s capacity is to be challenged, the challenger has to lead evidence to demonstrate the loss of capacity. The majority of evidence questioned why the Bill would create an unprecedented requirement across the board, to the effect that all individuals requesting assisted suicide and voluntary euthanasia would be subject to a test. However, the Committee believes that, in a situation such as this, the approach would be justified.
• The Bill would establish a procedure, one of the purposes of which would be to detect undue influence. However, the approvals necessary to proceed would be obtainable following two meetings with a medical practitioner and one other meeting with a psychiatrist, neither of whom would need to have previously had any contact with the requesting person. The question is whether this level of contact with these particular categories of person would give sufficient assurance that there had been no undue influence on the requesting person’s decision.
• The Bill attributes a meaning to the phrase “end of life assistance” that does not explicitly include any notion of hastening death. This use of terminology is confusing and arguably misleading and inconsistent with the member in charge’s stated reasons for proposing the Bill. It would have been unambiguous to use the terms “assisted suicide” and “voluntary euthanasia”.
• The Bill, in setting out eligibility requirements in Section 4, ostensibly provides for an objective standard based on finding life “intolerable”. The Committee believes, however, the standard set out is inherently subjective. Indeed, the member in charge placed great emphasis throughout the inquiry on her intention that the wishes and self determination of the requesting person be paramount. Such a test cannot, therefore, stand up as an objective test.
• A further eligibility requirement set out in the Bill would be based on being “permanently physically incapacitated to such an extent as not to be able to live independently”. This raised a number of equalities issues. The terminology used was aimed at capturing a small number of people who find life intolerable but could also apply to a wider group of people with a range of physical conditions or physical incapacity. This is symptomatic of the breadth of the member in charge’s intentions. The immense difficulty of drafting a provision that would capture all those that the member in charge means to include without extending to whole other groups should be recognised; this terminology is, however, extraordinarily wide.
• There are real problems in the Bill’s definition of “terminal illness” as it is based on a notion of timescale that may be difficult to ascertain.
• In relation to the eligibility requirement based on an inability to live independently, the Committee found evidence from organisations representing people with disabilities to be particularly compelling because of the way in which society may let an individual’s life be intolerable by neglecting to provide sufficient and appropriate support. Using the inability to live independently as an eligibility requirement for end-of-life assistance raises issues of definition, clarity and subjectivity similar to those relating to other terminology in the Bill, with the additional possibility of unintended consequences.
• The Bill does not specify any particular qualifications or experience for the designated practitioner and psychiatrist roles. The Committee shares the concerns raised in evidence about this issue but notes that this may raise competence, regulatory and legal issues. The Committee did not hear evidence that these issues had been explored.
• Points were also made about the age threshold. Some members found the threshold at 16 to be consistent with other legislation. Other members were sympathetic to the arguments in favour of setting the threshold at 18.
• Concerns were expressed on the lack of detail with regard to the requirement for the presence of the designated medical practitioner but believes that any medication administered during the end-of-life process should nonetheless be in the presence of a medical practitioner.
• The Committee is concerned that the setting of a limit of 28 days for the provision of end-of-life assistance could encourage a person to proceed prematurely.
• The Bill would not explicitly require the participation of any particular person or class of person in assisted suicide or voluntary euthanasia. Nor does it state explicitly that they would be able to refuse to take part. An absence of a requirement is not necessarily equivalent to a right to refuse. There were calls in the evidence for a form of ‘conscience clause’ to be specified. This may, however, fall within the ambit of regulation of the health professions and, therefore, outwith the legislative competence of the Parliament. It may be difficult for this Bill to find a satisfactory solution within legislative competence. The Committee believes, however, that, in legislation of this nature, a conscience clause should be included.
• Contrary to the assertions of the Policy Memorandum, the Bill could have a negative effect for disabled people. There are also potential issues of inequality in relation to remote areas where it could prove difficult to find locally practitioners and psychiatrists willing to participate.
• The Committee is not confident that equalities issues have been robustly considered in the preparation of this Bill. The Policy Memorandum asserts that the Bill will have a “positive impact on issues of equality” but does not appear to be able to support this claim. It is an established practice that Scottish Government bills and policies are impact assessed to ensure that a negative impact is not inadvertently created for equality groups. The member in charge has not followed this example and the Committee finds that, as a result, the consideration of the equalities impact of the Bill lacks rigour.
• Consideration of the Financial Memorandum uncovered weaknesses in its approach to estimating the number of assisted suicides and deaths by voluntary euthanasia that would occur if the Bill were enacted. In particular, no sufficiently sophisticated modelling has been undertaken. The Financial Memorandum also makes flawed assumptions about where costs would fall and is vague in respect of their scale. A further potential equalities issue – the possible differential impact on people from varying economic backgrounds – also appears to have been overlooked in terms of costs that may have to be met by individuals.

257. Overall, the majority of the Committee was not persuaded that the case had been made to decriminalise the law of homicide as it applies to assisted suicide and voluntary euthanasia, termed ‘end-of-life assistance’ in the Bill, and, accordingly, does not recommend the general principles of the Bill to the Parliament.

Friday 19 November 2010

The Committee scrutinizing Margo MacDonald's Bill have recommended that it be rejected – now it is time for MSPs finally to bury it

I have previously blogged about Margo MacDonald's End of Life Assistance (Scotland) Bill which seeks to legalise both assisted suicide and voluntary euthanasia and Scotland. I argued that Margo Macdonald has been seriously misleading both the Scottish people and Parliament itself about its likely effects.

The Committee scrutinizing the bill has now published its Stage 1 report and has emphatically recommended the Bill should be rejected.

MSPs will debate the bill next week at 2.55pm on Thursday 25 November with a vote late that evening. If voted out at that stage the bill will fall.

Doctors' leaders and campaigners have united to urge MSPs to reject controversial proposals to legalise assisted suicide.

The British Medical Association Scotland was among those who made the plea after a Holyrood committee said the case has not been made for changing the law to allow the practice.

Margo Macdonald MSP, who suffers from Parkinson’s disease, originally introduced the bill with the intention of legalizing so-called ‘assisted dying’ in Scotland but had faced widespread criticism over the scope, clarity and lack of safeguards in the proposed legislation.

The rejection of the bill by the committee, which was established in February this year to consider the general principles of the Bill and report on them to the Scottish Parliament, is the latest step in a long-running saga.

On 3 March 2010, the Committee launched a public call for evidence, inviting individuals and organisations to make written submissions with their views on the Bill. The consultation closed on 12 May 2010.

Of the 601 people and organisations who gave written evidence to the consultation on the Bill, only 6.5 per cent (39) were in favour of it. Scottish Parliament then called for and received Oral evidence.

The full report of the committee, which reviews and considers all this evidence, both written and oral, has now come to the conclusion that the bill should not proceed.

Care Not Killing, http://www.carenotkilling.org.uk/ an alliance of over 40 organisations promoting palliative care and opposing euthanasia, of which CMF is a core member, which made a written submission to the consultation along with giving oral evidence, has also published a detailed briefing Paper on the Bill. It has welcomed the conclusions of the committee.

CNK outlines why the bill should be rejected as follows:

The scope of the Bill is incredibly broad. It would offer assisted suicide to people who are to some degree dependent on others and would include those with life threatening and non life-threatening disabilities, and those with relatively common conditions such as, for example, insulin-dependent diabetes, heart or lung disease.
Tens of thousands of seriously ill and disabled people throughout Scotland would fall within its remit.

The Bill purports to allow assisted suicide (where a patient is provided with lethal drugs by a physician for self-administration). In fact it goes much further. It would also legalise euthanasia (where a physician administers lethal drugs to a patient directly).

The drafting of the Bill is vague and full of euphemisms and ambiguities. Among others, there is no definition of what it is to find life 'intolerable' and the methods by which life would be legally terminated are not identified.

The bill is not clear on what means can be used to end a person's life. One might assume that it is envisages lethal drugs but this is not specified and therefore the 'means of administration' might conceivably include gas (carbon monoxide or helium), hanging, a bullet or a push off a cliff.

Safeguards are seriously defective. Among others, there is real doubt that the suggested medical assessments would be sufficient to discern that the patient is not under external pressure to request assisted suicide.

The Bill contains no specified procedures by which doctors would report their involvement with an assisted suicide. This makes meaningful audit of how the law was working highly problematic.

It places responsibility for providing “end of life assistance” on the shoulders of Scottish doctors, for whom it contains no 'conscience clause' and the majority of whom would not be prepared to participate in implementing the proposals of the Bill.

The Bill is intended to 'enable a person to die with dignity and a minimum of distress'. This is already provided through good health care and particularly palliative medicine.

The vast majority of medical practitioners and all the Royal Colleges of Medicine do not support assisted suicide.

The Scottish Parliament has already had two opportunities to discuss assisted suicide. On both occasions the legalization of assisted suicide was convincingly rejected.
For society to accept assisted suicide or euthanasia means it agrees that some lives no longer have any meaning, value or worth.

Having assisted suicide legislation in place sends a message to vulnerable, ill, and elderly people that they should take up the option of assisted suicide so as not to be a burden.

Evidence from the Netherlands and the US state of Oregon – where assisted suicide is currently legal - shows that it is impossible to prevent abuses from occurring.

Almost 9 out of every 10 of the 600 responses to the Parliament's consultation opposed the Bill

Well over 20,000 people have signed up to the Care Not Killing postcard campaign opposing the Bill. This is by far and away the biggest campaign response since the Scottish Parliament was established.

The Scottish Parliament would be wise now to follow their own committee’s recommendations and bury this bill for good next Thursday.

Tuesday 16 November 2010

‘We have a charge from Christ to care for the weakest in society’ - Dr Trevor Stammers speaks on Channel 4 about abortion

Channel Four are showing a series of short films this week about different people’s views on abortion. Dr Trevor Stammers spoke tonight and you can watch the clip on the Channel 4 website. Here are some excerpted comments:

‘To me it’s an absolutely chilling thought that the Virgin Mary would have been a prime candidate for abortion these days.

As I doctor and a Christian I believe abortion harms women and society in general…In my heart of hearts I never believe that killing your unborn child is the best way forward

I think the profession as a whole feels a huge amount of unspoken shame about its increasing involvement with abortion not because women are sick but purely because children are viewed as a social inconvenience

I think that - those doctors who work full time - something happens to them... What must it do to you day after day pulling out bits of fetus from women’s wombs?

We have a charge from Christ to care for the weakest in society and who could be weaker than the baby in the womb?’

Don’t believe everything you read in the Washington Post - A compendium of the most recent medical evidence linking abortion and mental health

I recently blogged about an adjournment debate in the House of Commons in which Nadine Dorries MP spoke about the mental health consequences of abortion and argued the case for a law ensuring that women seeking abortion be offered information about the health consequences of their decision.

The day after the debate the Daily Telegraph published a letter from six consultant psychiatrists supporting Nadine Dorries' position and calling for a change in the law.

The letter noted that in March 2008, the Royal College of Psychiatrists issued a position statement in which they recognised that good practice in relation to abortion should include informed consent involving the provision of adequate and appropriate information regarding the possible risks and benefits to physical and mental health.

I was therefore interested to see just a few days later an article published in the Washington Post titled ‘The big lie about abortion and mental health’. The author, Brenda Major, argued as follows:

‘Rigorous U.S. scientific studies have not substantiated the claim that abortion, compared with its alternatives, causes an increased incidence of mental health problems. The same conclusion was reached in 2008 by an American Psychological Association task force, which I chaired, as well as by an independent team of scholars at Johns Hopkins University.’

I’m not sure if the Washington Post intends to grant column inches to those who might want to contest Major’s claim, but the claim has been since contested and I reproduce Professor Priscilla Coleman’s response to Major’s article here:

On Sunday, November 7, the Washington Post published an opinion by Dr Brenda Major titled ‘The Big Lie about Abortion and Mental Health.’ I would like to offer another perspective on the dishonesty permeating the scientific study of abortion and mental health and the dissemination of information on the topic. Like Brenda Major, I am a tenured full professor at a well-respected American university who has published peer-reviewed scientific articles in reputable journals. (In fact, my publication record far exceeds Dr. Major’s on the topic of abortion and mental health.)

Dr. Major is absolutely correct that an informed choice regarding abortion must be based on accurate information. An unbiased and valid synopsis of the scientific literature on increased risks associated with abortion would include depression, substance abuse, and anxiety disorders (including PTSD), as well as suicide ideation and behaviors. The body of literature on the subject is made up of hundreds of studies — including 30 in just the last five years — published in major medical and psychological journals throughout the world. The conscientious reader is encouraged to check the studies out. No lies, just scientifically derived information that individual academics, several major professional organizations, and abortion providers have done their best to hide and distort.

Dr Major’s opinion piece followed on the heels of a highly biased ‘Task Force Report on Abortion and Mental Health’ from the American Psychological Association. Six colleagues and I sent a petition letter to the APA criticizing their methods and conclusions; as a group, the seven of us in 2008 had published nearly 50 peer-reviewed articles indicating abortion is associated with negative psychological outcomes.

These two examples are just the latest in a long line of efforts to divert attention from sound published data on the emotional consequences of abortion. The literature now echoes the voices of millions of women for whom abortion was not a liberating, health-promoting choice: A conservative estimate from the best available data is 20 to 30 percent of women who undergo an abortion will experience serious and/or prolonged negative consequences. Yet a socio-political agenda seeks to keep the truth from women in order to ensure that the big business of abortion continues unimpeded.

Any interpretation of the available research that does not acknowledge the strong evidence now available in the professional literature represents a conscious choice to ignore basic principles of scientific integrity. The human fallout from such a choice: misinformed professionals, millions of women struggling in isolation to make sense of a past abortion, thousands who will seek an abortion today without the benefit of known risks, and millions who will make this often life-altering decision tomorrow without the basic right of informed consent. In publishing Major’s opinion without soliciting other voices on the topic, the Washington Post has perpetuated a serious injustice.

I note that the Association of Prolife American Obstetricians and Gynecologists (AAPLOG ) also has on their website evidence based conclusions from the world literature on the mental health disasters following abortion for many women, disasters ranging from substance abuse, to depression, to suicide.

Also worth reading (if you have the time) are AAPLOG’s comments on the ‘sweeping and strange conclusion’ of the American Psychological Association (APA) in their 2008 task force report .

Studies published in the last five years linking abortion and mental health

Bradshaw, Z., & Slade, P. (2005). The relationship between induced abortion, attitudes toward sexuality, and sexual problems. Sexual and Relationship Therapy, 20, 390-406.

Brockington, I.F. (2005). Post-abortion psychosis, Archives of Women's Mental Health 8: 53-54.

Broen, A. N., Moum, T., Bodtker, A. S., & Ekeberg, O. (2006). Predictors of anxiety and depression following pregnancy termination: A longitudinal five-year follow-up study. Acta Obstetricia et Gynecologica Scandinavica 85: 317-23.

Broen, A. N., Moum, T., Bodtker, A. S., & Ekeberg, O. (2005). Reasons for induced abortion and their relation to women's emotional distress: A prospective, two-year follow-up study. General Hospital Psychiatry 27:36-43.

Broen, A. N., Moum, T., Bodtker, A. S., & Ekeberg, O. (2005). The course of mental health after miscarriage and induced abortion: a longitudinal, five-year follow-up study. BMC Medicine 3(18).

Coleman, P. K. (2005). Induced Abortion and increased risk of substance use: A review of the evidence. Current Women's Health Reviews 1,21-34.

Coleman, P. K. (2006). Resolution of unwanted pregnancy during adolescence through abortion versus childbirth: Individual and family predictors and psychological consequences. Journal of Youth and Adolescence, 35, 903-911.

Coleman, P. K. (2009). The Psychological Pain of Perinatal Loss and Subsequent Parenting Risks: Could Induced Abortion be more Problematic than Other Forms of Loss? Current Women's Health Reviews, 5, 88-99.

Coleman, P. K., Coyle, C. T., & Rue, V.M. (2010). Late-Term Elective Abortion and Susceptibility to Posttraumatic Stress Symptoms, Journal of Pregnancy, vol. 2010, Article ID 130519.

Coleman, P. K., Coyle, C.T., Shuping, M., & Rue, V. (2009), Induced Abortion and Anxiety, Mood, and Substance Abuse Disorders: Isolating the Effects of Abortion in the National Comorbidity Survey. Journal of Psychiatric Research, 43, 770- 776.

Coleman, P. K., Maxey, C. D., Rue, V. M., & Coyle, C. T. (2005). Associations between voluntary and involuntary forms of perinatal loss and child maltreatment among low-income mothers. Acta Paediatrica, 94(10),--76-1483.

Coleman, P. K., & Maxey, D. C., Spence, M. Nixon, C. (2009). The choice to abort among mothers living under ecologically deprived conditions: Predictors and consequences. International Journal of Mental Health and Addiction 7, 405-422.

Coleman, P. K., Reardon, D. C., & Cougle, J. R. (2005). Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy. British Journal of Health Psychology, 10 (2),255-268.

Coleman, P. K., Reardon, D. C., Strahan, T., & Cougle, J. R. (2005). The psychology of abortion: A review and suggestions for future research. Psychology and Health, 20, 237-271.

Coleman, P.K., Rue, V.M. & Coyle, C.T. (2009). Induced abortion and intimate relationship quality in the Chicago Health and Social Life Survey. Public Health, 123, 331-338.DOI: 10.1016/j.puhe.2009.01.005.

Coleman, P.K., Rue, V.M., Coyle, C.T. & Maxey, C.D. (2007). Induced abortion and child-directed aggression among mothers of maltreated children. Internet Journal of Pediatrics and Neonatology, 6 (2), ISSN:1528-8374.

Coleman, P. K., Rue, V., & Spence, M. (2007). Intrapersonal processes and post-abortion relationship difficulties: A review and consolidation of relevant literature. Internet Journal of Mental Health, 4 (2).

Coleman, P.K., Rue, V.M., Spence, M. & Coyle, C.T. (2008). Abortion and the sexual lives of men and women: Is casual sexual behavior more appealing and more common after abortion? International Journal of Health and Clinical Psychology, 8 (1), 77-91.

Cougle, J. R., Reardon, D. C., & Coleman, P. K. (2005). Generalized anxiety following unintended pregnancies resolved through childbirth and abortion: A cohort study of the 1995 National Survey of Family Growth. Journal of Anxiety Disorders, 19, 137-142.

Coyle, C.T., Coleman, P.K. & Rue, V.M. (2010). Inadequate preabortion counseling and decision conflict as predictors of subsequent relationship difficulties and psychological stress in men and women. Traumatology, 16(1), 16-30. DOI:10.1177/1534765609347550.

Dingle, K., et al. (2008). Pregnancy loss and psychiatric disorders in young women: An Australian birth cohort study. The British Journal of Psychiatry, 193, 455-460.

Fergusson, D. M., Horwood, L. J., & Boden, J.M. (2009). Reactions to abortion and subsequent mental health. The British Journal of Psychiatry, 195, 420-426.

Fergusson, D. M., Horwood, L. J., & Ridder, E. M. (2006). Abortion in young women and subsequent mental health. Journal of Child Psychology and Psychiatry, 47, 16-24.

Gissler, M., et al. (2005). Injury deaths, suicides and homicides associated with pregnancy, Finland 1987-2000. European Journal of Public Health, 15, 459-463.

Hemmerling, F., Siedentoff, F., & Kentenich, H. (2005). Emotional impact and acceptability of medical abortion with mifepristone: A German experience. Journal of Psychosomatic Obstetrics & Gynecology, 26, 23-31.

Mota, N.P. et al (2010). Associations between abortion, mental disorders, and suicidal behaviors in a nationally representative sample. The Canadian Journal of Psychiatry, 55(4), 239-246.

Pedersen, W. (2008). Abortion and depression: A population-based longitudinal study of young women. Scandinavian Journal of Public Health, 36, No. 4, 424-428.

Pedersen, W. (2007). Childbirth, abortion and subsequent substance use in young women: a population-based longitudinal study. Addiction, 102(12), 1971-78.

Reardon, D. C., & Coleman, P. K. (2006). Relative treatment for sleep disorders following abortion and child delivery: A prospective record-based study. Sleep, 29 (1), 105-106.

Rees, D. I. & Sabia, J. J. (2007). The Relationship between Abortion and Depression: New Evidence from the Fragile Families and Child Wellbeing Study. Medical Science Monitor. 13(10): 430-436.

Suliman et al. (2007) Comparison of pain, cortisol levels, and psychological distress in women undergoing surgical termination of pregnancy under local anaesthesia versus intravenous sedation. BMC Psychiatry, 7 (24), p.1-9.

Saturday 13 November 2010

Videos on Christianity and medicine from the recent ACMA Conference are now available on the Ararat TV website

In an earlier blog posting I wrote about Armenia as a country with a wonderful Christian past and future.

I had the privilege of visiting there recently to speak at the ACMA (Armenian Christian Medical Association) National Conference.

Ararat TVM (www.atvm.tv) producer Syuzanna Voskanyan has edited some of the talks at the conference which are now available with consecutive translation by Shushan Ghazaryan.

If you are interested you can watch them on the Ararat TVM website

The pro-euthanasia lobby’s reaction to Frances Inglis’ sentence reveals their agenda and ignores key facts of the case

Under British law mercy killing (ie. euthanasia voluntary or involuntary) is treated as murder under the Murder Act 1965 and carries a sentence of life imprisonment. The judge has discretion in sentencing for murder depending on the facts of the case and may lessen the sentence in the light of mitigating factors such as ‘provocation’ or ‘diminished responsibility’.

Life imprisonment however does not mean life imprisonment. The standard sentence is fifteen years but the range is very broad. The Jigsaw Killer Stephen Marshall got 36 years. On the other hand extreme Frances Inglis got only nine years and this has now been reduced by the court of appeal to five.

The pro-euthanasia lobby’s ultimate objective is to decriminalise all mercy killing. They are attempting to do so using an incremental strategy and by starting with very modest initial objectives. Attempts to legalise overt mercy killing in Britain have always been unsuccessful and so the pro-euthanasia lobby have therefore focused on the softer target of assisted suicide (helping people to kill themselves).

Encouraging or assisting a suicide is illegal under the Suicide Act 1961, but carries sentence of only ‘up to 14 years imprisonment’. The judge has discretion in sentencing here also and in practice many of those convicted (and there are very few convictions at all) receive only suspended sentences, meaning in effect that they do not go to prison at all. Kay Gilderdale was a recent case in point.

Lord Joffe’s Assisted Dying for the Terminally Ill Bill, defeated by 148 votes to 100 at second reading in the House of Lords on 12 May 2006, was the first of two failed recent attempts to legalise assisted suicide for the terminally ill. In like manner, Lord Falconer attempted to amend the Suicide Act in 2009, by way of the Coroners and Justice Bill, a piece of legislation paradoxically designed actually to tighten the suicide law. His aim was to decriminalise taking ‘loved ones’ abroad for assisted suicide but the measure was defeated by 194 to 141. In less than two weeks Margo MacDonald will try again with her End of Life Assistance Bill in Scotland.

Because of the repeated failures to change the law in parliament the pro-euthanasia lobby have shifted their focus to the courts. Debbie Purdy managed, by way of the Supreme Court, to force the Director of Public Prosecutions to publish the criteria by which he decides whether or not a prosecution for assisted suicide is in the public interest.

These criteria I have previously argued are fundamentally flawed in that they have pandered to the agenda of the pro-euthanasia lobby by making prosecution less likely when the act is ‘wholly motivated by compassion’. This has effectively changed the working of the law by shifting the focus from ‘intention’ (a testable quality) to ‘motivation’ (a quality very difficult to assess objectively). It is therefore not surprising that we are seeing very few convictions.

The case of Tony Nicklinson is an attempt to do for the Murder Act what Debbie Purdy has done for the Suicide Act – to force the DPP to create concessions in sentencing for mercy killing – ie. Euthanasia.

In the meantime the other goal of the pro-euthanasia lobby is to get Parliament to review the Murder Act with the ultimate aim of decriminalising mercy killing.

This is demonstrated in the reaction we see to the Inglis judgement. Sarah Wootton, Chief Executive of Dignity in Dying, said after the hearing: ‘Whilst we do not condone Mrs Inglis's actions, given that she directly ended her son's life without his consent, it is clear that her motives were selfless, and we do not think that her actions should be unduly punished because murder law is not equipped for compassion.’

Ms Wootton’s aim is to build momentum for a review of the Murder Act. The British Humanist Association (BHA) has similarly said that the law needs to be reformed to distinguish between cases of ‘mercy killing’ and murder. The language used is that of Dignity in Dying (DID).

Naomi Phillips, BHA head of public affairs, said: ‘Today’s judgment demonstrates that the courts are bound by a restrictive law which fails to distinguish between where a person has compassionately assisted another to die, and where that was done with malicious intent or murder.

‘However, it is for parliamentarians not judges to make the legal changes necessary in order to ensure that cases of “mercy killing” and of murder are seen and treated differently under a reformed law.

‘Ultimately, we want assisted dying to be legalised in the UK. Without those legal reforms, those who are vulnerable remain at risk because legal safeguards, which would accompany the legalisation of assisted dying, are not in place to protect them from coercion or other malice.

We need a law on assisted dying that is sensible, ethical and forward-thinking, that both upholds people’s fundamental human right to die with dignity, in a manner of their choosing, and which protects those who are motivated by compassion to assist another's death.’

The BHA’s overt objective (legalising euthanasia whether voluntary or involuntary as in this case) is broader than that of DID (assisted suicide for the ‘terminally ill’) but this only goes to show how seamless these various categories are.

What these groups conveniently choose to ignore are the facts of this case. As has been made clear in the judgement, Tom Inglis’ brain damage was at least in part the result of his mother’s earlier attempt to kill him.

In their ruling, Lord Judge said that Mrs Inglis – who was not in court - not only killed her son without considering the rest of the family, her initial failed attempt on his life made his condition worse.

‘The appellant’s actions were deliberate and premeditated, and her compulsive objective was indeed to kill her son,’ he said.

‘She was motivated throughout by her personal, unremitting conviction that she should release him from the living hell his limited life had become… She tried to kill Thomas and did eventually kill him without a thought to the feelings of anyone else, including his father and brothers.’

He added: ‘Harsh as it is to have to say it, she had contributed to the very sorry condition from which, on the day of his death, Thomas was suffering.’

If we were to change the law to decriminalise mercy killing (in this case involuntary euthanasia) we would be removing legal protection from all vulnerable people whose lives are judged by some other person as not worth living.

We would be saying that one person, on the basis of such a judgement, should be able to break into a hospital ward and kill them ‘out of compassion’ and get off scot-free.

The effect would be to encourage more acts of this kind. It is precisely for this reason that the law against mercy killing, even for so-called compassionate motives, must stay firmly in place.

Friday 12 November 2010

The Inglis judgment should send a strong signal that it is not acceptable to take another person’s life, even in desperation.

A woman from East London who was found guilty of murder after giving her brain-damaged son a lethal heroin injection to end his ‘living hell’ has lost an appeal against conviction.

Frances Inglis, 58, of Dagenham, was jailed for life with a minimum term of nine years at the Old Bailey in January.

Three judges at the Court of Appeal in London have rejected her conviction challenge, but reduced the minimum period she must serve before becoming eligible to apply for parole to five years.

Lord Judge said: ‘There is no doubt at all that the appellant was subjected to great stress and anguish, but dealing with it briefly and starkly, there was, as our analysis of the evidence underlines, not a scintilla of evidence that when the appellant injected the fatal dose of heroin into her son she had lost her self-control.’

Examining the concept of mercy killing in the ruling, he said: ‘We must underline that the law of murder does not distinguish between murder committed for malevolent reasons and murder motivated by familial love. Subject to well-established partial defences, like provocation or diminished responsibility, mercy killing is murder.’

Tom Inglis (22) suffered severe head injuries when he fell out of a moving ambulance in July 2007. His mother, who worked as a carer for disabled children, first tried to end his life two months after the accident when he was being treated at Queens Hospital in Romford, Essex. His heart stopped for six minutes but he was revived.

Prior to this incident Tom’s condition had been slowly improving to the extent that he was able to open his eyes and move his limbs. But according to Prosecutor Miranda Moore QC, his mother had come to the view that he would not get better and she wanted him to die.

The mother-of-three was charged with attempted murder before successfully trying again in November 2008 after barricading herself in her son’s room at the Gardens nursing home in Sawbridgeworth, Hertfordshire, and supergluing the door. Jurors returned majority verdicts of 10-2 and the trial judge told them that they could not have had ‘a more difficult case’.

At the recent appeal hearing, her QC Alan Newman told the judges that she feared her son would die in agony and gave him the injection to end his life ‘peacefully and painlessly’. Inglis believed he was in ‘constant pain’.

It was argued on her behalf that the trial judge should have left the issue of provocation to the jury. Referring to the fact that Inglis had not lost her self-control, Lord Judge said all the evidence was to the contrary. He said that far from lacking or losing self-control - an ‘essential’ ingredient for the defence of provocation - she was ‘completely in control of herself’. The judges ruled that her appeal against conviction was ‘not arguable’.

Lord Judge, in his summing up, gave a strong defence of the dignity and worth of all human life and made it crystal clear that it is not acceptable to make judgments about the worth or value of the life of another person and act on it in this way. He said:

‘The fact is that he was alive, a person in being. However brief the time left for him, that life could not lawfully be extinguished.

Similarly, however disabled Thomas might have been, a disabled life, even a life lived at the extremes of disability, is not one jot less precious than the life of an able-bodied person.

Thomas's condition made him especially vulnerable, and for that among other reasons, whether or not he might have died within a few months anyway, his life was protected by the law, and no one, not even his mother, could lawfully step in and bring it to a premature conclusion.’

The fundamental purpose of the law is to protect vulnerable people and this judgment is a very important restatement of the law.

The sentence of five years is actually very low for a murder charge reflecting the fact that the judges have clearly chosen to temper justice with mercy.

However it is most significant that whilst in possession of all the relevant material, they still considered a substantial period in custody as appropriate to the facts in this case.

The law prohibiting all intentional killing, including that for alleged compassionate motives, is clear and right. It provides a strong disincentive to abuse and exploitation whilst allowing judges discretion in sentencing to reflect the circumstances of the individual case. Disabled people will sleep more easily in their beds in the light of this judgment knowing that the law still offers them some protection.

This judgment should send a strong signal that it is not acceptable to take another person’s life, even in desperation.

Sunday 7 November 2010

New advances in embryo testing may result in higher success rates for IVF but at what cost?

Two new embryo screening tests have been recently developed that researchers believe will increase success rates for women having a health baby after IVF treatment.

At present only about 30% of women under 35 have a baby following IVF and this percentage drops with age falling to 10% by age 40.

The new tests enable abnormal embryos to be indentified five days after fertilisation and before being implanted in the womb.

If embryos judged unlikely to survive are not implanted, it follows that the chance of a pregnancy reaching term is higher.

The first new test involves measuring the uptake of glucose by early embryos. Glucose is an energy source essential to growth and its low uptake is therefore a marker of poor growth in the early embryo.

Researchers at the University of Melbourne in Australia have developed the technique.

Their research involved 50 patients undergoing IVF. 32 of the women had a positive pregnancy test after embryo transfer and 28 babies were born. These 28 babies resulted from the embryos which had the highest glucose uptake. Controversially the method also has the potential to predict the gender of an embryo prior to implantation, as female embryos appear to take up more glucose than males.

The second new test involves determining the number of chromosomes in the developing embryo. The BBC has run the story this morning apparently after receiving a press release from specialists at CARE Fertility in Manchester. This will probably make it big news. However the story is not new and was covered by the Daily Telegraph and Bionews (amongst others) over a week ago. Those interested in knowing more about the technique will far more usefully spend their time examining these accounts.Tony Rutherford, chair of the British Fertility Society, expects the test will take two to three years to develop.

Aneuploidy (read more here)– an abnormal number of chromosomes – is responsible for a high percentage of pregnancies that spontaneously abort and is increasingly common with age.

But fertility specialists in the US state of New Jersey are claiming to be able to double IVF success rates by selecting out embryos with either too many or two few chromosomes. A Denver specialist has explained why the test is of particular importance to women over 35. He said, ‘By the time you’re in your mid-30s about 50 per cent of embryos are abnormal; by 40, 75 per cent are; and by 42, 85 to 90 per cent are’.

Fertility drops off rapidly after age 30 probably mainly for this reason. So it appears that the demand for this technology will be greater the more women, for whatever reason, delay trying for a baby.

So what of the cost?

The NHS currently provides funding for one cycle of IVF for women who have met the clinical definition of infertility, providing they have an identifiable cause to their infertility. After that couples have to pay. According to the Human Fertilisation and Embryology Authority (HFEA) the average cost of one cycle of IVF including drugs is between £4,000 and £8,000.

Preimplantation genetic diagnosis (PGD) – determining if the embryo is genetically abnormal before implantation – currently costs between £1,000 and £2,000 but it is likely that these new embryo screening tests, should they become commercially available, will cost considerably more. Cheaper options overseas will no doubt fuel more IVF tourism in future. Regardless, in an era of shrinking health budgets this is technology that is increasingly going to be only the reserve of the rich.

But money is only one part of the cost of IVF. There is also the emotional cost of being on the emotional roller coaster of a treatment for which results are not immediately obvious (confirming a successful pregnancy takes time) and where there is still a high probability of failure. 30% success rates are also 70% failure rates.

And finally there is the moral cost. This new technology is essentially eugenic. It involves identifying and discarding (or not implanting) embryos that are judged to be abnormal. It might be argued that many of these would not have survived pregnancy anyway - embryos for example with trisomy 16 inevitably do not survive pregnancy – but a significant number do.

These include babies with Down Syndrome (Trisomy 21), Edwards Syndrome (Trisomy 18), Patau Syndrome (Trisomy 13) and Turner’s Syndrome (XO), who carry disabilities varying in form, number and severity. Some of these are treatable and some aren’t.

Are we therefore saying that embryos which can not look forward to a life without disability should not be given the chance to live?

Interestingly the Pope is quoted in the Hindustan Times just yesterday on this very issue. He said, ‘it is indispensable that new technological developments in the field of medicine never be to the detriment of respect for human life and dignity, so that those who suffer physical illnesses or handicaps can always receive that love and attention required to make them feel valued as persons in their concrete needs.’

He added that the number of people with Down syndrome ‘has declined mostly because a good number of them are eliminated before they are born.’

In December 2008, the Vatican issued a document affirming the ‘dignity of the human embryo’ which listed biomedical techniques considered ‘illicit’ by the Roman Catholic Church. These included in vitro fertilisation, cloning, the therapeutic use of stem cells, producing vaccines from embryo cells and the ‘morning-after’ pill.

Such practices go against the ‘fundamental principle’ that the dignity of the person must be recognised from conception until natural death, it said.


New report claims that junior doctors' training 'puts patients at risk' but will the government be prepared to pay for the real solution required?

A new report, Foundation for Excellence, this week has claimed that patients are being put at ‘unnecessary risk’ because inexperienced junior doctors are being ‘thrown in at the deep end’.

The 128-page report, led by Professor John Collins of Oxford University (interestingly one of my old surgical bosses!) for Medical Education England, analysed the two-year foundation programme for trainees, which they now join after graduating from medical school.

The report claims that trainee doctors in their first two working years are often being asked to perform ‘beyond their level of competence and without adequate supervision’.

In the wake of the report’s publication Health Secretary Andrew Lansley has asked Medical Education England ‘to work with the profession, the service and medical Royal Colleges to take forward the (33) recommendations as swiftly as possible’.

I was particularly interested in the comments of John Black, president of the Royal College of Surgeons, who said that while any doctor had to expect ‘difficult situations’, this should be mitigated by having a ‘proper team structure in place’.

He commented: ‘Unfortunately these team structures have been eroded to the point of vanishing by the introduction of the ill-conceived EU regulation which restrict doctors’ working hours, leaving junior doctors isolated and without adequate supervision.’

I did my first two years as a junior doctor in a district general hospital in New Zealand in the early 1980s. We generally worked a ‘one in four’ call (averaging 72 hours on duty per week) with three of us (all in our first two years post qualification) covering a 500 bed hospital, including acute admissions and casualty, which served a population of about 100,000 people.

Consultants and registrars were not in the hospital after hours but could be called in from home.

On my very first weekend on call we dealt with a major road accident with four young male casualties. Fortunately the two of us (juniors) called first to the scene had done an attachment in our final student (trainee intern) year in ‘anaesthetics and intensive care’ and ‘coronary care’ respectively which was most fortunate given that the first patient had a cardiac arrest in the resuscitation room shortly after arrival. We were able to intubate, rehydrate and cardiovert him before the more senior staff arrived although he later died from what were very serious generalised injuries.

The second patient needed an emergency tracheostomy in the A&E department for an obstructed airway (thankfully we did not have to do that!) and the third needed to be flown out to a major centre for emergency neurosurgery. The fourth was admitted with a head injury that did not prove serious. All three did well.

It was a baptism of fire but we survived and I went on to specialise in general surgery. During my junior years I was once working in a hospital where we did 80 hour shifts every fourth weekend starting at 0800 on Friday and finishing at 1700 (or later) the following Monday. You usually got some sleep when things quietened down in the small hours but it was not guaranteed and I remember one Monday afternoon, after a busy weekend on call, being unable even to insert a cannula out of sheer exhaustion.

What encouraged the hospital to continue with these ridiculous hours was the fact that it was far cheaper to employ juniors on long shifts because we only were paid only 30% of our usual hourly wage for each hour worked over 40 hours per week. It wasn’t until junior doctors called a national strike in the 1980s for the introduction of penal rates (ie at least our normal hourly wage for each hour’s overtime) that the practice stopped.

Working hours for most juniors dropped overnight and hundreds of overseas doctors were drafted in to fill the gaps in the shifts (which brought its own problems as many were not adequately trained).

The European Working Time directive has brought similar changes in the UK.

I don’t miss working those hours but one thing I think today’s juniors do miss out on is the teamwork and continuity of care that was our general experience. We were almost always rostered on with the same team – usually a houseman (foundation year junior), registrar (specialist trainee) and consultant.

The advantage of this was that you grew together as a team and all looked after each other’s interests. Moreover it was I believe better for training - an apprentice model of learning really did operate. In addition we didn’t have to deal with the perils of patient handover at the end of a shift. We looked after the patients we admitted until discharge and only passed them over to other teams if they were already better known to another consultant. We also didn’t have to face today’s dreaded ‘week of nights’ shifts.

Whilst today’s juniors do not have to face attempting to function whilst exhausted I feel they do miss out on the strength of the team relationships we enjoyed and the benefits to learning from following patients all the way through the course of their hospital stay.

And whilst at times the supervision was less than adequate (and like today at times unacceptably so) it wasn’t all bad and in some ways better than today’s situation.

Judging by Professor Collins’ report there is still a lot of improvement needed.

The challenge will be to maximise patient safety, good supervision, excellent training, team-working and continuity of care. This will require financial investment. And, like for us, I suspect that is the real issue.