Criminology Research Council grant ; (22/90)
Advances in medical knowledge and expertise have resulted in changes in the causes and timing of death in most western countries. People are now living longer and chronic, degenerative diseases which cause a gradual deterioration in health over long periods have replaced communicable diseases as the major causes of death. So too the survival rate amongst premature babies with low birth weights or those with congenital defects has improved.
The very success of medicine in treating illness means that death is postponed until old age, but people may live long periods with chronic, painful, debilitating conditions which are not terminal, or not immediately fatal. So too, while the positive benefits of advances in medical treatments have led to increased life expectancy and greater longevity, many treatments, especially those of an invasive nature or those used to treat the severely or chronically ill, also involve some element of risk, pain, and the possibility of greater or lesser permanent damage or temporary side effects. Increasingly, too, considerable medical resources are expended in prolonging life in situations where survival is transitory or accompanied by severely impaired quality of life.
The continuation of this successful and active pursuit of curing illness and preserving life may cause problems for patients suffering from terminal or grave, chronic illness. It can also cause dilemmas for medical practitioners and members of other health professions where the harm caused to patients by treatment appears to outweigh the benefits. In the future it may also pose difficulties in financing health care delivery in societies where equitable access to health care is regarded as a fundamental right irrespective of means.
The research addressed the first two of these issues, and probed whether medical practitioners and nurses were ever asked to hasten the death of their patients and the reasons such requests were made. In doing so an attempt was made to reveal if patients or their families ever wanted to halt the prolongation of life and whether this was prompted by a perception that the disadvantages of medical treatment outweighed the beneficial effects. The study revealed that it was common for medical practitioners and nurses to receive such requests from their patients.
Almost half of those surveyed had received requests to hasten death by withdrawing treatment from patients, and almost half medical practitioners had received such requests from the families of patients. A considerable minority of nurses surveyed had received requests from the families of patients. Lesser proportions of both medical practitioners and nurses had also received requests to hasten the death of patients by taking active steps. It was found that the most common reasons for requests to hasten death were persistent and irrelievable pain, terminal illness and incurable conditions.
The study also revealed that an overwhelming majority of medical practitioners and nurses believed such requests could be considered rational. The main reasons for this ascription were situations where patients suffered pain, were near death or experienced an extremely poor quality of life.
Recently there has been a shift in the balance of issues confronting medical practitioners away from simply attempting to keep patients alive, towards finding answers to the question of when to allow patients to die. The survey data on the proportions of patients and their families who request that death be hastened either by withdrawing treatment or taking active steps indicates the extent to which patients and their families wish to participate in medical treatment decision-making during the terminal stages of illness. More importantly, it suggests that a considerable proportion of patients and their families believe this can no longer be left to medical practitioners alone. Finally, the data also provides some evidence on the extent of the public perception that some members of the medical profession may persevere too long or may be over zealous in their pursuit of all treatment options.
An overwhelming majority of medical practitioners surveyed reported that they had suggested to patients that no treatment be undertaken, while a considerable majority had suggested that treatment be discontinued. That this is a recent phenomenon is indicated by the fact that much higher proportions of young medical practitioners had suggested withholding and withdrawal of treatment than those over the age of 60 or those who had been in practice more than 30 years.
The study confirmed a lack of unanimity concerning the moral, ethical and legal status of decisions to withhold or withdraw medical treatment, where the effect of these actions would be to hasten the death of a patient. The research found that there was some preparedness by medical practitioners and nurses to overlook the law and take active steps to hasten the death of their patients. Eighteen per cent of both groups had undertaken active euthanasia.
The survey revealed majority support amongst both medical practitioners and nurses for guidelines to be established to clarify the legal position of medical practitioners regarding withholding and withdrawal of medical treatment. Doctors were less interested than nurses in clarifying the legal ambiguities of decisions made in this area, and this is possibly because the current situation allows considerable personal flexibility and autonomy, with little fear of prosecution for those who wish to withdraw or withhold treatment.
Medical practitioners were divided on the question of the legalisation of active euthanasia, with considerable and almost equal minorities opposed to, or in favour of changes in the law. Nursing views were far more polarised, and a clear, although small majority of nurses were in favour of the legalisation of active euthanasia under some circumstances. The proportion who were undecided was similar for both medical practitioners and nurses.
Among those who favoured the legalisation of active euthanasia there was considerable consensus that terminal illness and intractable pain and suffering constituted circumstances in which active euthanasia could or should be legal. However, there were minority opinions that poor quality of life, mental disability and physical handicap should also be valid circumstances for active euthanasia. The diversity of opinion on these issues invites caution to ensure that in framing guidelines or legislation, current abuses which result from enthusiastic and aggressive pursuit of the aim of preserving life do not become transmuted into abuses due to lack of adequate protection of life.