Is the Doctrine of Double Effect legalising Euthanasia by the back door
Is the Doctrine of Double Effect legalising Euthanasia by the back door?
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In order to fully discuss this question, the definitions of both double effect and euthanasia must be established and the medical, moral and legal aspects compared. Lord Edmund Davies surmised how these aspects may lead to radically different interpretations when he stated that "killing both pain and patient may be good morals but it is far from certain that it is good law"1. In light of this it is fundamental that it is established whether or not euthanasia has become a legalised tenet of British justice "by the back door" so to prevent miscarriages of justice in a medico-legal sphere. It is worth including here the plea by Pope John Paul II in his encyclical Evangelium Vitae: "I renew the appeal that I made in the Encyclical to the whole Church: to scientists and doctors... especially to jurists and lawmakers. It will be through everyone's commitment that the right to life will be concretely applied in this world. Only in this way will we overcome that sort of silent, cruel selection by which the weakest are unjustly eliminated."2 Indeed, the Hippocratic Oath swears that "I will neither prescribe nor administer a lethal dose of medicine to any patient even if asked nor counsel any such thing nor perform the utmost respect for every human life from fertilization to natural death"3. This stance will be challenged in the body of the essay.
Double Effect
Historically, double effect is closely associated with the Roman Catholic Church and Thomas Aquinas. The doctrine itself may originate in a letter of Saint Paul although it is widely believed that the principle of double effect originated with Thomas Aquinas' discussion of the permissibility of self-defense in the Summa Theologica4. Aquinas observed that "Nothing hinders one act from having two effects, only one of which is intended, while the other is beside the intention"5. The rule of double effect is a conceptually and psychologically complex doctrine that distinguishes between permissible and prohibited actions by relying heavily on the clinician's intent. More recently the doctrine has become has been seen as being relevant to the discussion of Medical Ethics and the legal implications of administering pain relief in terminally ill patients. Although higher than usual levels of pain relief can be tolerated by totally conscious and competent patients, opium derivates have a side effect of reducing breathing, thus hastening death. In R v Adams in 1957, Hedley J stated that "He [the Doctor] is entitled to do all that is proper and necessary to relieve pain even if the measures he takes may incidentally shorten life"6. As can be established from Hedley J's quote, double effect, especially when seen through the prism of medical ethics requires a distinction between foreseeing an outcome and intending it in order for double effect to be legally sound. As one will appreciate, this distinction, legally, is of paramount importance. Lord Goff summarised in Airedale v Bland that "such a decision may properly be made as part of the care of the living patient, in his best interests; and, on this basis, the treatment will be lawful. Moreover, where the doctor's treatment of his patient is lawful, the patient's death will be regarded in law as exclusively caused by the injury or disease to which his condition is attributable."7 Nicholas Pace discusses the legal implications in his essay "Withholding and Withdrawing Medical Treatment" saying that "The acceptance in law of double effect does not rest on the "no intention" point of view, but instead would be based on "no causation" so that the cause of death is disease rather than the drug"8.
The importance of this distinction and the legal tenets of justice surrounding the doctrine of double effect have given rise to four necessary points which are generally seen as the authority for practice9. These points are outlined below:
. The nature of the act performed must be morally indifferent
2. Only the good effect is intended by the agent.
3. There must be a proportionate reason for allowing the expected bad effect to occur.
4. The good effect must not be performed by means of the bad effect; there must be a distinction between the two.
It can therefore be seen that there are many problems with the doctrine of double effect. These mainly arise through the morality of the act which is at best subjective when the issue of intention is raised. The distinction between a directly intended and a merely forseen consequence comes down to looking at: a) whether a clear distinction can always be drawn between consequence that an agent directky intends and those merely forseen and 2) Is the distinction morally relevant in itself?10 For example the administering of the analgesic may kill the patient and the medical practitioner is almost certain to know this. Can it thus be argued that it is done with the right intention? It may mask an (immoral) intention to kill the patient. Indeed Dr Timothy Quill admits the difficulty when the patient starts talking about wanting to die. In this case, he argues, can you still say that you're not intending to help them to die when that is one of their main purposes in taking a higher dose of medicine?11
Attention is drawn to R v A where the religious and moral objections by parents in separating their conjoined twins were debated in court. Although the defence argued that the principle of double effect would negate the surgeon's criminal responsibility, the judge stated that it could have "no possible application"12 as the surgeons could in no way be acting in good faith towards one twin even if it benefited the other. It was noted in the judgement that in 1977 a similar case arose in Philadelphia. The catholic nurses received comfort based on the double effect doctrine believing that one of the conjoined twins was, by its very nature, sacrificed for the benefit of the other. The carotid artery was tied, not to terminate the life of the sacrificed twin but to preserve the life of the other. This is a tenuous sequence of thought which has had no application to the principle of double effect in the United Kingdom. Double effect in the United Kingdom relates to the patient's comfort rather than his or her premature death13. Thus it philosophically relates to the terminally ill patient whereas euthanasia relates to both the terminally ill patient and the incurable patient.
Euthanasia
Debate about the morality and legality of euthanasia is, for the most part, a phenomenon of the second half of the twentieth century. Certainly, the ancient Greeks and Romans did not consider life needed to be preserved at any cost and were, in consequence, tolerant of suicide in cases where no relief could be offered to the dying or, in the case of the Stoics and Epicureans, where a person no longer cared for his life. In the sixteenth century, Thomas More, in describing a utopian community, envisaged such a community as one that would facilitate the death of those whose lives had become burdensome as a result of 'torturing and lingering pain'14. On the 6th June 2003, Lord Joffe's Patient Assisted Dying Bill was debated in the House of Lords. This bill hoped to "enable a competent adult who is suffering unbearably as a result of a terminal or a serious and progressive physical illness to receive medical help to die"15. However, the bill was defeated at the second reading.
Etymologically euthanasia comes from the Greek "eu" and "thanatos" which together mean "a good death"16. The Pro-Life Alliance however defines euthanasia as: "Any action or omission intended to end the life of a patient on the grounds that his or her life is not worth living."17 Acts and omissions are of great importance in UK law. An act is a positive action administered by an agent while an omission is seen as an indifferent action. Euthanasia is understood practically when a peaceful death is brought about deliberately and intentionally, usually by a medic. With euthanasia, a healthcare professional, by a calculated act or omission initiates a causal sequence that results in the patient's death. With assisted suicide, the healthcare professional may either help or may fail to prevent a patient completing a course of action which results in his or her own death. In the former case, the healthcare professional rather than the patient is ultimately in control even when it occurs with patient consent. In the latter, although the boundaries may sometimes appear blurred, the patient remains the agent (or the act ceases to be suicide)18. The issue of intention is of principle importance as the medic has the requisite mens rea for murder if active or involuntary euthanasia occurs. In the Report on Medical Ethics 1994, the Bishops said "Because human life is a gift from God to be preserved and cherished ... both Churches are resolutely opposed to the legalisation of euthanasia even though it may be put forward as a means of relieving suffering"19. Thus it is of benefit to examine the different "types" of euthanasia and the consequences of each.
Merritt, A Circuit Judge in America suggested that there are several types of euthanasia, including (1) the refusal of medical treatment that would prolong life by a competent, terminally ill patient, (2) so-called "double effect" euthanasia, where a terminally ill patient in severe pain is given pain medication which relieves pain but also cuts short the patient's life; and (3) "physician assisted suicide" which kills the patient through means other than the withdrawal of life support or "double effect" euthanasia". The District Court made the point as follows: "Michigan law does not prohibit doctors from prescribing medication which has the "double effect" of relieving pain while also hastening death or substantially increasing the risk of death.
There is a widespread belief that passive euthanasia, where life-sustaining or life-prolonging measures are withdrawn or withheld, is morally acceptable because steps are simply not taken which could preserve or prolong life (and so a patient is allowed to die), whereas active euthanasia is not, because it requires an act of killing. The distinction, despite its widespread popularity, is very unclear. Whether behaviour is described in terms of acts or omissions (which underpins the alleged distinction between active and passive euthanasia), is generally a matter of pragmatics.
The most controversial "type" of euthanasia is active euthanasia which, in English law, occurs when treatment is administered to intentionally take the life of a person. Problems occur in distinguishing euthanasia from murder. The most prominent case concerning active euthanasia was the so-called "Dr Arthur's case"20 where a drug "to relieve suffering" and also designed to stop the child seeking sustenance was orally administered to a seriously ill downs syndrome baby. However, Dr Arthur was acquitted of a murder charge as the jury found him not to have had the necessary intention of killing the child; rather bring about his peaceful death. Indeed, doctors are generally acquitted or given a suspended sentence in these cases. Again, this can be seen in R v Cox21 where Potassium Chloride, a drug used in lethal injections and with no pain-relieving merits was administered by Dr Cox on the request of the patient.
This leads on to voluntary euthanasia where the patient is competent and has consented to Euthanasia. During the 1970's and 1980's court cases in The Netherlands culminated in agreement being reached between the legal and medical authorities to ensure that no physician would be prosecuted for assisting a patient to die as long as certain guidelines were strictly adhered to. These guidelines were established to permit physicians to practise voluntary euthanasia in instances where a competent patient had made a voluntary and informed decision to die. During the 1990's Australia's Northern Territory gained the first legislative approval to enable physicians to practise voluntary euthanasia. Subsequent to the Act's proclamation in 1996 it faced a series of legal challenges from opponents of voluntary euthanasia. In 1997 the challenges culminated in the Australian National Parliament overturning the legislation when it prohibited Australian Territories from enacting legislation to permit euthanasia. In Oregon, in the United States, "Death with Dignity" legislation was introduced in 1997 to permit physician-assisted suicide albeit subject to strict rules. Later in 1997 the Supreme Court of the United States ruled that there is no constitutional right to physician-assisted suicide. However, the Court did not preclude individual States from legislating in favour of physician-assisted suicide. The Oregon legislation has, in consequence, remained operative and has been successfully utilised by a number of people. In November 2000 The Netherlands passed legislation to legalise the practice of voluntary euthanasia. The legislation passed through all the parliamentary stages early in 2001 and so became law. The Belgian parliament passed similar legislation in May 2002.
In the UK, voluntary euthanasia is prohibited. Pretty v UK is the leading case precedent on voluntary euthanasia. Pretty claimed that Article 2, concerned with her right to life, of the Human Rights Act and Article 3 which protected her from inhuman and degrading treatment were being violated as her motor neurone disease continued. It was argued that her absolute right not to be so subjected, together with her right to personal autonomy, outweighed any duty of the State to protect her life. The BMA, however, considered that establishing it as a "right" for those who demand it will inevitably raise questions about why such a "right" should be denied to others such as the senile or mentally ill, for whom it may constitute a harm22.
The central ethical argument for voluntary euthanasia for example, is that respect for persons consequently demands respect for their autonomous choices because autonomy presupposes competence. In exercising autonomy or self-determination people take responsibility for their lives and, since dying is a part of life, choices about the manner of their dying and the timing of their death are, for many people, part of what is involved in taking responsibility for their lives.
Advocates of voluntary euthanasia contend that if a person is suffering from a terminal illness; as a direct result of the illness, either suffering ...
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The central ethical argument for voluntary euthanasia for example, is that respect for persons consequently demands respect for their autonomous choices because autonomy presupposes competence. In exercising autonomy or self-determination people take responsibility for their lives and, since dying is a part of life, choices about the manner of their dying and the timing of their death are, for many people, part of what is involved in taking responsibility for their lives.
Advocates of voluntary euthanasia contend that if a person is suffering from a terminal illness; as a direct result of the illness, either suffering intolerable pain, or only has available a life that is unacceptably burdensome (because the illness has to be treated in ways which lead to her being unacceptably dependent on others or on technological means of life support; has an enduring, voluntary and competent wish to die (or has, prior to losing the competence to do so), expressed a wish to die in the event that conditions unable without assistance to commit suicide, then there should be legal and medical provision to enable her to be allowed to die or assisted to die. Dr Stephen Lodwig's23 case however, suggested that if voluntary euthanasia is to be legally permitted it must be against a backdrop of respect for professional autonomy. Thus, if a doctor's view of her moral or professional responsibilities is at odds with the request of her patient for euthanasia, provision must be made for the transfer of the patient's care to another who faces no such conflict.
However, these conditions are somewhat restrictive in their scope. In particular, the conditions concern 24access to voluntary euthanasia for those who are terminally ill. While that expression is not free of all ambiguity, for present purposes it can be agreed that it does not include the bringing about of the death of, victims of quadraplegic paralysis or those who suffer from alzeheimers disease. The onus of establishing lack of voluntariness or lack of competence should subsequently be on those who refuse to accept the person's choice, for example R v Z 2004.
In Passive Euthanasia the issue of consent becomes somewhat blurred. Passive euthanasia involves the withdrawal or withholding of treatment, the non-treatment of a treatable condition and the refusal of treatment. This is based on a morally significant difference between inactivity and action. Lord Mustill stated in the case of Bland that "the English criminal law...draws a sharp distinction between acts and omissions. If an act resulting in death is done without lawful excuse and with intent to kill, it is murder. But an omission to act with the same result and the same intent is in general no offence at all"25.
In Re a Ward of Court heard in the Supreme Court of the Republic of Ireland it was held that "As the process of dying was a part and ultimate consequence of life, the right to life necessarily implied the right to have nature take its course and to die a natural death and not to have life artificially maintained by the provision of nourishment by abnormal, artificial means which had no curative effect and which were intended merely to prolong life. The right to life, as so defined, did not include a right to have life terminated or death accelerated"26.
Non voluntary Euthanasia - when the patient is competent but has not consented to euthanasia suggests the ending of life of paternalistic grounds. This is certainly not lawful as it overrides the patient's own autonomy and in that respect amounts to murder. The Remmelink Committee found that 45% of 1,000 non voluntary euthanasia cases the treatment of pain was no longer adequate to help suffering. The impossibility of treating pain adequately was the reason for killing 30% of patients while 70% of patients were killed for reasons such as low quality of life, futility of life and also influenced by family and friends rather than inadequate pain control27.
Assisted Suicide
Suicide can be distinguished from euthanasia by the person who brings about the final act from which subsequently death occurs. Whatever the motive of the person assisting, by definition "suicide" cannot occur without the patient's cooperation. If the patient does not actively consent to the act, it becomes either non-voluntary euthanasia or murder. It could be argued, therefore, that assisted suicide may be less open to potential abuse than euthanasia because the patient's cooperation must be verified by witnesses at various stages which can be separated in time. The 1994 Oregon legislation, for example, permitted doctors to prescribe a lethal dose for competent patients with a life expectancy lower than 6 months. In the UK however, Section 2 of the Suicide Act 1961 remains uncompromising in its terms: "A person who aids, abets, counsels or procures the suicide of another, or an attempt by another to commit suicide, shall be liable on conviction on indictment to imprisonment for a term not exceeding 14 years."28
Terminal Sedation
Terminal Sedation is generally known as "sedation for intractable suffering in the dying patient,"29 whereby a terminally ill person with irremediable suffering is sedated to unconsciousness. If fluids are not provided to such an unconscious patient, death soon ensues. Orentlicher30 has equated terminal sedation with euthanasia because the withdrawal of food and water "does nothing to relieve the patient's suffering but only serves to bring about the patient's death." Nevertheless, under Quill, a state may allow terminal sedation if it is "based on informed consent and the double effect. Just as a state may prohibit assisting suicide while permitting patients to refuse unwanted lifesaving treatment, it may permit palliative care related to that refusal, which may have the foreseen but unintended double `effect' of hastening the patient's death"31.
When looking to the medical sphere in the case of terminal sedation, terminally ill patients may have intolerable pain, shortness of breath, delirium, or persistent vomiting that is refractory to the usual therapies. Intolerable pain may be caused by several conditions while intolerable shortness of breath can result from several conditions, too, including lung and other cancers, chronic obstructive lung disease, and congestive heart failure32 Terminal sedation is then maintained until the patient dies which is usually within a few days either from the illness itself or from the withholding of nutrition and hydration. On closer examination, however, terminal sedation at times is tantamount to passive euthanasia. However, the difference between terminal sedation and passive euthanasia is that (it is argued) the patient dies from the induced stupor or coma. It is the medically created state of diminished consciousness that renders the patient unable to eat and not the patient's underlying disease. In an article by John Luce and Ann Alpers, they cite Quill and associates and argue that terminal sedation does not conform with the rule of double effect because "life-prolonging therapies are withdrawn with the intent of hastening death."33 However, terminal sedation may be compatible with the rule of double effect if the medical profession intend only to relieve pain and suffering and to honour patients' informed refusal, assuming that the patients or their surrogates regard nutrition and hydration as unwanted therapies.
However, it may be easier to use the principle of double effect when trying to account for the idea of terminal sedation. According to the principle of double effect, medics may take steps that might hasten the patient's death as long as the steps constitute a reasonable effort to treat the patient's suffering and the patient's death is not intended. For example, it is permissible to give analgesics or sedatives to alleviate a patient's pain even if the drugs might halt the patient's breathing. However, the principle of the double effect justifies only the sedation that is part of terminal sedation. It is difficult to see how it justifies the withdrawal of food and water during terminal sedation, for that step does nothing to relieve the patient's suffering but only serves to bring about the patient's death. If it is argued that the withdrawal of food and water is a permissible act, then the act constitutes either passive euthanasia or the premise that terminal sedation is permissible only because the patient's inability to eat or drink results from an underlying disease.
What is Death or how can it be understood?
Death is more complicated than one would first think. UK law generally holds that a person who suffers brain-stem death is dead, but some campaigners argue such a definition is defective. For example, they argue, there is no agreed way to define when the brain is dead. And even if there were, why should the death of the brain count as death of the person if other organs - such as the heart - are still functioning?
Up until the 1960's the cardio-pulmonary criteria of death was used whereby the death of a person was constituted by the irreversible cessation of breathing and heartbeat. However this has been undermined over the past 40 years but the development of medical technology i.e. assisted ventilation and heart bypass machines. During the 1970's, the criteria used to establish death was the notion of "brain death" although in 1995 an article was published in the Journal of the Royal College of Physicians entitled "The Criteria for the Diagnosis of Brain Stem Death". This reinforced the idea that brain stem death was the correct term rather than brain death, explaining that: "It is suggested that 'irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe' should be regarded as the definition of death" 34. According to the Intensive Care Society, there are two ways that death can be determined. For people suffering cardio-respiratory arrest (including failed resuscitation), death can be certified as usual by a registered medical practitioner following cessation of heart and respiratory activity. The doctor has to be certain that, in a normothermic patient, there has been inadequate circulation to the brain for long enough to ensure that there has been irreversible damage to the vital centres in the brain stem.3536.
In the case of determination of death by brain stem testing, medical practitioners must follow the Code of Practice issued by the Department of Health in 199837. Brain stem death produces a state of irreversible loss of consciousness associated with the loss of central respiratory drive (apnoea). It was accepted as being equivalent to somatic death by the World Medical Association in 1968 as it represented a state when "the body as an integrated whole has ceased to function". In the UK this position was accepted in a 1976 memorandum from the Conference of the Medical Royal Colleges and their Faculties38. This allowed discontinuation of mechanical ventilation in patients whose brain stem had irreversibly ceased to function and also allowed organ donation from brain stem dead heart beating donors. The criteria for the diagnosis of brain stem death have also been adopted by the courts in England and Northern Ireland for the certification of death. Despite all this, there are some aspects of the performance of brain stem testing that remain ambiguous. In these areas the ICS Working Group has come to a consensus that it is felt represents best practice in the current state of knowledge.
Brain stem death is diagnosed in three stages:
. It must be established that the patient has suffered an event of known aetiology resulting in irreversible brain damage with apnoeic coma, i.e. the patient is deeply unconscious, mechanically ventilated with no spontaneous respiratory movement.
2. Reversible causes of coma must be excluded.
3. A set of bedside clinical tests of brain stem function are undertaken to confirm the diagnosis of brain stem death.
"Morality" and right to life
Another way of defending double effect is to argue that a physical harm is not always a moral evil.4 It is the reason why harm is inflicted which determines whether it is a moral evil- the intention is either beneficence or non-malificence. But the doctrine does not permit actions which would usually be wrong, because they are a means to a good end, in a particular situation. Opposition to euthanasia cannot be based on an objection to achieving good effects through bad effects. The second argument is that the patient's own ethical evaluation of a method or an outcome should determine whether it is good or bad. Advocates of euthanasia are subjective when defending the right off a competent patient while they use an impressionist argument when defending euthanasia in a patient who is mentally incompetent39.
In the British Medical Journals discussion paper "Euthanasia & physician assisted suicide: do the moral arguments differ?" it was stated that:
"Ultimately we do not believe that the arguments are sufficient reason to weaken society's prohibition of intentional killing... That is the cornerstone of law and of social relationships. It protects each one of us impartially; embodying the belief that we all are equal... individual cases cannot reasonably establish the foundations of a policy which would have such serious and widespread repercussions. We believe that the issue of euthanasia is one in which the interests of the individual cannot be separated from the interests of society as a whole"40. In most moral, social, and legal realms, people are held responsible for all reasonably foreseeable consequences of their actions, not just the intended consequences. The medical profession are not exempt from this expectation. This understanding of moral responsibility encourages people to exercise due care in their actions and holds them responsible for that which is under their control. The important moral question is whether the risk of foreseeable harm is justified by an action's good effects. It is the principle of proportionality that determines when the risk of undesirable consequences is justified.
Doctrines concerning how life should be treated cannot be easily be separated from the legal and sociological aspects of morality. Using morality in establishing normative law is a subordinate theorem. Lex injusta non est lex has been a principle, and a description, of natural law since common law and equity were separate concepts. For many centuries the Court of Equity sought to remedy legal iniquity, and judges avoid reaching unconscionable decisions because the law ought to be congruous with morality, being legally less good law if it were not..
Natural law is primarily concerned with the idea that morality is the keystone in many legal arguments and law follows as a by-product. Rousseau states that law "is that holy imprescriptable law which speaks to the heart and reason of man"41 where it is up to individual conscience to decide upon justice as "conscience never deceives us". Yet the idea of unjust is a human concept. Therefore can natural law, in prescribing the nature and thus the concept of law be pedagogical in terms of dictating a "morality" for humans to abide by in communities? If morality is then taken as a human concept in that life is based upon experience rather than innate feeling, it shows that morality is not decided on by a God but by new experience which leads to an emotionally conditioned response. Thus it can be logically concluded that morality is a series of conditioned responses that have been codified over time to form a concrete morality. Indeed, this is consistent with the concepts propounded by natural lawyers such as' "(it is) the first moral principle" to choose "the possibilities which are compatible with integral human fulfilment"42. No choice can bring overall fulfilment thus the principle of integral human fulfilment is a sociological ideal to guide society to legally "right" choices.
Religion appears confused on the issue of the right to die. In the opening paragraph, John Paul II urges respect and importance to be placed on the right to life, not death. This reinforces the view that euthanasia is recognised as relatively modern conception hence the contentious debating on the issue. This appears to stem from fear of the Nazi regime where a policy of eugenics was practised. Yet passive euthanasia, or refraining from doing anything to keep the patient alive, has been in practice since four centuries before Christ; and in the centuries that followed neither the Christians nor the Jews significantly changed this basic idea. In continuation, Pope Pius XII in 1958 emphasized that we may 'allow the patient who is virtually already dead to pass away in peace' 43.
The changing nature of sociological morality and the notions which attempt to analyse the concept of legal repercussions hinder the description of law in that any attempted description must take into account the fluidity and subjectivity of social communities upon which the concept of law directly relates to. However, a description of the use of the law is in nature, for the positivist, as for the realist, irrespective of content and is legally binding unless set aside by another Court. On this view the need for a decision, any decision, is more important than that the decision have a particular content, however congenial. This "decision" is typically a concise description of what the law has become. Yet the consequence of any decision has the potential to change what law is, both descriptively and conceptually.
The main philosophies when looking at medico-legal issues of life and death are underpinned by Utilitarian and Kantian philosophies. A utilitarian model, favoured by John Stuart Mill and Jeremy Bentham emphasises consequences. Eudemonistic utilitarians state that a good death is a happy death while Hedonistic utilitarians argue that a good death is a painless death. A Kantian model, on the other hand, emphasises autonomy, rights, and respect. The central tenet to this philosophy is that people should not be and cannot be treated like mere things, stating that "man cannot have the power to dispose of his life"44. The difference is that Kantians emphasize the importance of a patient's right to decide while Utilitarians look only at consequences.
It would appear that once it is accepted that there is such a thing as a morally acceptable act of intentional killing, there really is no distinction between voluntary, non-voluntary and involuntary acts of killing. What needs to be considered here is the sanctity of life. Pursuing the principle of moral absolutes leads to the prohibition of certain things. Contrary to a moral absolute is Vitalism and is a very different sort of moral from the sanctity of life principle. The good of life is violated by an act of intentional killing although the good of life is not violated by not promoting it at all cost in all circumstances.45 This is epitomised in part of the Hippocratic Oath whereby it is sworn that "Into whatever patient setting I enter, I will go for the benefit of the sick". The benefit to the sick is important as it re-emphasises the duty of care owed from the medical profession to patient while benefit suggests an emotive duty of care for the patients emotional state. Indeed in Van der Wal's study 71% of patients reported significant emotional suffering in addition to physical suffering46.
Value of life and autonomy
"People are not people because they are accepted, but rather they are accepted because they are people. They are people because they are capable of valuing life and it is wrong to kill them because they do value life" so said Harris47. Is it, as Harris suggests, right to keep people alive because they do, as a person, intrinsically value life? People are autonomous: they are motivated to act morally not through inclination, not through coercion but through their own perception of duty in accordance with universal laws. To deny autonomy is to deny the respect that should be his as a self-ruling, independent and rational agent. The report of the Select Committee on Medical Ethics in 1994 expressed the view that "the prohibition against intentional killing is the cornerstone of law and social relationships which protects each of us impartially, embodying the belief that all of us are equal"48. This misses a vital point that although in theory all are equal, when suffering is involved this fails to be the case. Can one quantify equality between a patient dying painfully of a terminal illness and a person in good health? That we are all alive is a base equality but this belief emasculates an individuals being and their human rights.
The idea of autonomy is central to the debates regarding treatment. Medical paternalism, when treatment is justified despite a patient's objections, on the face of it denies patient autonomy. However, Savulescu recently introduced the "rational non-interventional paternalist" model of the patient-doctor relationship. Patients need to make their own decisions if they are to be fully autonomous. Rational non-interventional paternalism undermines the importance of patient choice and so threatens autonomy. Doctors should provide an evaluative judgment of the best medical course of action, but ought to restrict themselves to helping patients to make their own choices rather than making such choices for them49
But, it might be said, what if a person is racked with pain, or befuddled because of the measures taken to relieve her pain, and so not able to think clearly and rationally about the alternatives? It has to be agreed that a person in those circumstances who wants to die cannot be assumed to have a competent, enduring and genuinely voluntary desire to die. However, it is possible for a person to indicate in advance of losing the capacity to give competent, enduring and voluntary consent, how she would wish to be treated should she become terminally ill and be suffering intolerably from pain or from loss of control over her life. 'Living wills' or 'advance declarations' are legally useful instruments for giving voice to people's wishes while they are capable of giving competent, enduring and voluntary consent, including to their wanting help to die. These need to be readily available for the medical profession. Perhaps, though, what is really at issue in this objection is whether anyone can ever form a competent, enduring and voluntary wish about being better off dead rather than continuing to suffer from an illness before actually suffering the illness.
Existing case law is based upon the presumption of bodily integrity. John Locke's assertion that "every Man has a Property in his own Person. This no Body has any Right to but himself"50 which underpins much of the moral dialogue in this area Egoists think that everyone has a right to life but only if it brings benefit while a deontologist believes that a right to life is alienable. This "right to life" generates certain duties in others. These are namely the duty of non interference and the duty of service (from others). Now that medical science can prolong life indefinitely it is now not the right to life that is important, but the right of a patient to die.
The Bishops, sitting in the House of Lords, argued that the extension of autonomy to allow euthanasia would limit the autonomy of doctors, since "patients cannot and should not be able to demand that doctors collaborate in bringing about their deaths"51. However, The British Humanist Association suggested that sanctity of life was not a principle on which legal structures should be based, since it depended on a religious outlook which not everyone shared. They suggested that "it is particularly hurtful to require someone who does not believe in God or afterlife to suffer intolerable pain or indignity in deference to a God or afterlife he does not accept"52. The Voluntary Euthanasia Society suggests that
"the phrase 'respect for life' may reflect the present day consensus on the matter more accurately than the absolutism of 'sanctity of life'"53.
Consent
The law of consent is based on the following related principles: desirability of self-determination and the respect for individual integrity. The nature of consent requires three separate elements; Voluntariness, Capacity and Knowledge. These three elements are interdependent rather than independent54. According to dicta in R v C, "a patient is competent if he or she can: comprehend information given to him or her in a clear and concise way, believe it and retain it long enough to weigh it up and make a decision"55.
If treatment is carried out without the patients consent then it is, prima facie illegal. It also gives rise to a case in Tort through battery and/or negligence. Cardozo J stated that "every human being of adult years and a sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without the patient's consent commits an assault"56. The legal standpoint on liability in medical negligence is the Bolam test. This occurs when a body (no matter how small) of medical opinion supports the action that was taken. However, the Bolam test has been criticised for allowing doctors to determine the legal standard of medical practice. However the court has qualified that it is not bound to accept the medical evidence as conclusive although precedent would suggest that it does.
Nevertheless, autonomy remains the first ethical principle for removing life-sustaining treatment, even though most critically ill patients must exercise their autonomy through surrogates or living wills because they cannot make medical decisions themselves. Ethics here reflects law because informed consent and informed refusal are the primary legal principles that justify this practice. In Vacco57, the Court drew further distinctions between assisted suicide and withholding and withdrawal of life support. "Everyone, regardless of physical condition, is entitled, if competent, to refuse lifesaving medical treatment; no one is permitted to assist a suicide," the Court wrote. "When a patient refuses life-sustaining medical treatment, he dies from an underlying fatal disease or pathology; but if a patient ingests lethal medication prescribed by a physician, he is killed by that medication."58
Consent and patient autonomy are arguably the lynchpin when debating the right to life and the right to death. That assisted suicide and voluntary euthanasia have not yet been widely decriminalised is probably best explained along the lines that have frequently been offered for excluding consent of the victim as a justification for an act of killing, namely the difficulties thought to exist in establishing the genuineness of the consent. It is relevant here to look at the aspect of law whereby the patient cannot consent himself. In this case the doctrine of "best interest" is considered. This is seen in Airedale NHS Trust v Bland whereby the sanctity of life was held not to be absolute. Thus the cessation of medical treatment did not violate the patient's autonomy as the patient no longer had any interest in being kept alive by medical treatment.
In the United States, the withholding and withdrawal of life support is legally justified primarily by the principles of informed consent and informed refusal, both of which have strong roots in the common law. The application of these principles to the care of the critically ill began in the Quinlan case, in which the New Jersey Supreme Court held that a patient had the right to refuse mechanical ventilation, and that, because she was vegetative and could not exercise that right directly, her parents could act as surrogates for her59. The California Court of Appeals took a similar approach in the Barber case, in which it held that physicians charged with murder had not committed an unlawful act when, with permission from a patient's family, they removed nutrition and hydration from a comatose patient. The United States Supreme Court accepted the principle that a competent person's right to forgo treatment, including nutrition and hydration, is a liberty interest protected under the Fourteenth Amendment to the Constitution.
Treatment of those under the age of consent
Treatment of those under the age of consent is a contentious ethical issue. When concerning the principle of double effect it is worth looking to Re J where Lord Donaldson MR identified the relevant principles in these terms:
"What doctors and the court have to decide is whether, in the best interests of the child patient, a particular decision as to medical treatment should be taken which as a side effect will render death more or less likely. This is not a matter of semantics. It is fundamental. At the other end of the age spectrum, the use of drugs to reduce pain will often be fully justified, notwithstanding that this will hasten the moment of death. What can never be justified is the use of drugs or surgical procedures with the primary purpose of doing so."60 In Re J (A Minor) Lord Donaldson of Lymington MR stated that: 'The doctors owe the child a duty to care for it in accordance with good medical practice recognised as appropriate by a competent body of professional opinion . . . This duty is, however, subject to the qualification that, if time permits, they must obtain the consent of the parents before undertaking serious invasive treatment"61.
In A National Health Service Trust v D it was held according to Part 3B of the guidance drawn up by the British Medical Association Withholding and Withdrawing Life-prolonging Medical Treatment: Guidance for Decision Making (2001): '. . . If the child's condition is incompatible with survival or where there is broad consensus that the condition is so severe that treatment would not provide a benefit in terms of being able to restore or maintain the patient's health, intervention may be unjustified. Similarly, where treatments would involve suffering or distress to the child, these and other burdens must be weighed against the anticipated benefit, even if life cannot be prolonged without treatment.'62
In the case of National Health Service Trust v D the consensus was that the medical team in charge of the child's care should be allowed to proceed the way they thought best. It was identified that this would not breach either Article 2 or Article 3 which included the child's right to die with dignity, of the child's human rights. The declaration was granted that the medics could treat the child without artificial ventilation unless "such a course seemed inappropriate to the doctor in charge of him"63.
It seems, from the above cases, that children are subject to the same rights as adults when considering both double effect and passive euthanasia. This hinges more on the Human Rights Act rather than being an issue of consent however. The rights of suffering individuals are party not so much to consent but that matter of rights and their best interests. As argued above by Lord Donaldson, double effect as a principle is universal in its scope. However it is then difficult to tally the notion of double effect and euthanasia, at least passive, being separate entities in the eyes of the law.
Palliative Care
It is often said that it is not necessary nowadays for anyone to die while suffering from intolerable or overwhelming pain. Palliative care and hospice care is available. Palliative care has been advocated by the many that challenge euthanasia and assisted suicide as a means to relieve dying patients. However, Dr A Billings in his journal article on Palliative Care states that: "Although palliative care... is usually effective, some patients continue to suffer despite the best palliative efforts; up to 35% of hospice patients report severe pain in the last week of life"64. While both good palliative care and hospice care make important contributions to the care of the dying neither is a panacea. But, far more importantly, even high quality palliative care commonly exacts a price in the form of side effects such as nausea, incontinence, loss of awareness because of semi-permanent drowsiness.. For those who prefer to die in their own way and in their own time neither palliative care nor hospice care may be attractive. For many dying patients it is having their autonomous wishes frustrated that is a source of the deepest distress. It has to be borne in mind not everyone who is dying is suffering because of the pain occasioned by their illness. For those for whom what is intolerable is their dependence on others or on machinery, the availability of effective pain control will be quite irrelevant.
Quill and colleagues note that human intention is complex when faced with dying. Wilson et al demonstrated this complexity in a study of the administration of sedatives and analgesics during the withholding and withdrawal of life support, in which physicians indicated that they ordered drugs to hasten death, albeit primarily to decrease pain, anxiety, and dyspnoea, in 39% of critically ill patients65. Similarly, in a survey conducted by Asch, 16% of a sample of critical care nurses reported that they had engaged in assisted suicide or euthanasia while trying to relieve suffering, often without physician's knowledge66. This begins as double effect in the "trying to relieve suffering" yet the intention to engage in euthanistic practice emasculates the doctrine. Christian Barnard, at the World Euthanasia Conference, was quoted as saying, "I believe often that death is good medical treatment because it can achieve what all the medical advances and technology cannot achieve today and that is stop the suffering of the patient"67.
Where does the law stand on each? ECHR and UK
When looking at euthanasia and double effect through the prism of the legal sphere it is claimed that whatever the morality of an individual's deciding for herself that her life is no longer of value to her, that should provides no basis for the formulation of public policy. Law tends to be more concerned with the facts rather than as an emotive response to an individuals suffering. However when looking through a medical prism there are arguments in a very different direction. The patient's right to benefit from medical treatment and also to be autonomous in deciding that benefit is important. However this, legally, cannot infringe on a medical professionals right to be free from prosecution under criminal law. The Human Rights Act has become increasingly instrumental in defining what the law is and what the rights of the patient are.
The European Court of Human Rights generally upholds that life is sacred and its judgments, in the case of Pretty v UK et al, reflect this. The Human Rights Act is of vital importance in developing case law and precedent. In March 2004, the European Court of Human Rights awarded Carol Glass and her son David 10,000 Euros compensation in a case that was dismissed by UK Courts. The European Court of Human Rights held that David's Article 8 right to privacy, and in particular his right to physical integrity, had been breached. This followed a UK case of Burke v GMC 2004 in which it was established by the GMC that there were a number of areas where the judgment had left the law unclear. The BMA stated, in a press release afterwards that "This was in particular in relation to the circumstances in which treatment may be withdrawn when incompetent patients have not left clear instructions about what they would consider to be "intolerable". It is also not clear to what extent patients can "require" treatments other than artificial nutrition and hydration"68.
In an earlier case of NHS Trust A v M; NHS Trust B v H in 2001 the court had to consider a contravention of Article 2 (right to life) of the European Convention for the Protection of Human Rights and Fundamental Freedoms 1950. The case involved the question of whether a discontinuance of nutrition and hydration constituted an "intentional deprivation of life"69. It was argued that if this did not then the article would impose a "positive obligation to provide life sustaining treatment". Article 3 was also mentioned in relation to how the patient would die and whether that article could be invoked to ensure the patient could die with dignity. The protection of individuals' human rights is of paramount importance, especially since the Human Rights Act was passed in 1998. The "rights" enshrined in this are interpreted restrictively in that the sanctity of all life is more important that individual autonomy. As noted earlier, the Voluntary Euthanasia Society believes that absolutism of sanctity of life should be replaced by right to life. This would enable a non-religious position to be considered in light of personal autonomy and professional belief.
Criminal Responsibility and Case Precedent
The question of whether double effect negates the necessary elements of intention or causation for the crime of murder is of vital importance. In the full text of R v A, criminal responsibility is discussed: "We received interesting submissions... in which they suggested that the doctrine of double effect would relieve the surgeons of criminal responsibility in these circumstances"70. In most cases where double effect occurs it does constitute a bona fide argument. Lord Scarman, in Gillick v. West Norfolk and Wisbech Area Health Authority remarked that "the bona fide exercise by a doctor of his clinical judgement must be a complete negation of the guilty mind"71. This has been widely criticised. The law here appears to separate intention from guilty intention. It is impossible to perceive this concept as then it would apply to all areas under law. The definition of intention under Woollin still holds good under law and as such the diversion to guilty intention is avoidable. In immediate subsequence to the consideration of intention, lie the key concepts of actus reus and mens rea. It is important to analyse the actus reus and mens rea elements under the principle of double effect.
Professors Ian Kennedy and Grubb criticise the doctrine of double effect in so far as it is advanced as negating the necessary elements of intention or causation for the crime of murder, saying: "The more appropriate analysis is as follows: the doctor by his act intends (on any proper understanding of the term) the death of his patient and by his act causes (on any proper understanding of the term) the death of his patient, but the intention is not culpable and the cause is not blameworthy because the law permits the doctor to do the act in question."72 Dr Timothy Quill supports this difficulty with this "intention" and the "ability to foresee but not intend the act" in double effect. He argues that if the patient is near death or in great pain, and starts talking about being "ready to die" and as a consequence wanting a higher dose of pain medication this creates a moral dilemma for the doctor73. How then can the very principle of double effect work as it is, by its very nature based on a precept that the act performed must be morally indifferent and the "bad" effect must not be intended. At this point however, the doctor has the requisite mens rea for the crime of murder and the doctrine becomes merged with euthanasia as the intention and action will be to kill the patient.
This poses a difficulty for the performance of medical duties under the Hippocratic Oath. It is imperative for the medical profession to repudiate all possible undertones of euthanistic practice. The notes of Drs Walker, Ashton and Hallet in R v Glass all stressed that the administration of morphine was not intended to kill the first applicant but to relieve his distress. Dr Hallet observed in his notes that the doctors had stressed that the 'use of morphine is NOT euthanasia - it is to relieve [the first applicant's] distress'"74. This highlights the difficulties in merging law and medical ethics as one concept as it is duty to a patient v duty to society as a whole.
The case of Bland involved a further step: the House of Lords held that under judicial control it was permissible to cease to take active steps to keep a person in a permanent vegetative state alive. It involved the notion of a distinction between doctors killing a patient and letting him die. These are at present the only inroads on the sanctity of life principle in English law. The cessation of treatment in the Bland case was omission rather than an Act therefore the doctors are not liable to be prosecuted under criminal law as they are not under a duty to continue it. It relies on hope being abandoned for the patient and therefore acting, not just in the best interest of that patient but also of his family.
There is a distinct paradox and indeed irony in the way the legal profession approach medical problems. It is ironic that when it was considered by the medical profession not to be in Anthony Bland's best interest and that he had no further interest in being kept alive his hydration and nutrition were withdrawn yet when an autonomous patient makes a careful decision, usually over a lengthy time period, it is counted not to be in their best interests even if they themselves have no further interest in being kept alive and will die within weeks.
The Select Committee for Medical Ethics at point 259 considered suggestions that a new offence of "mercy killing" should be created75. However, there was a significant question as to whether the law could or should make a distinction between them. In order to make this distinction, mercy killing would have to be adequately defined as "compassionate". The difficulties in proving the intention of compassion would involve drawn out legal processes, semantics and also too subjective a grounding for legislation.
Slippery Slope Argument
There is nothing logically inconsistent in supporting voluntary euthanasia but rejecting non-voluntary euthanasia as morally inappropriate. A simplistic view is that the medical profession, if allowed to practice euthanasia will, as a direct result of their support for voluntary euthanasia, be psychologically driven to practise non-voluntary euthanasia. Comparisons are drawn to abortion and the ease with which it is now possible to enjoy this benefit. Abortion is now better seen in an amoral sense as it has eschewed the moral principle behind which the Abortion Act 1967 rests upon. The conern is, ironically, that if euthanasia is legalised, patient's will lose their autonomy to doctors who adopt a paternalistic approach.
However studies concerning this "slippery slope" argument have been carried out in the 1995 by Van der Maas et al76. No evidence was found to suggest that a patients voluntary choice in having assistance to die was being compromised. It emerged that the decision to end life was taken after extensive consultation with the medical profession and family members and, according to the reserachers, the principle of double effect is the most commonly occuring means to end life although this is negated academically by the specified intention. It was also noted that in few cases there was no consultation with relatives because families in The Netherlands strictly have no final authority to act as surrogate decision-makers for incompetent persons. Indeed, Professor Dworkin considered that it would not be possible always to be totally confident that a request for euthanasia was truly voluntary and not the result of pressure or coercion. But he suggested that a combination of legislative provision and social response could minimise the likelihood of such abuse77.
Conclusion
In the UK legal system, is it possible for anything to be legalised "by the back door"? One has to begin from the premise that double effect is legal. Although it is an accepted practice and has been debated in the courts it is difficult to give a definite legality to the concept due to the very subjective "intention" which must be either morally good or morally indifferent. Given the nature of the UK courts historically, they are wary of subjectivity, trust and intention as the basis for a successful case. It is worth harking back to the earlier suggestion for which the Bolam test has been criticised in allowing doctors to determine the legal standard of medical practice. Such cases where there have been positive interventionist steps taken by the doctor which affect life expectancy and outcome need to be distinguished from cases where the patient has a hopeless prognosis where medical treatment including hydration and nutrition is not considered to be achieving any benefit for the patient and is therefore not in the patient's best interests, In such cases where medical treatment is discontinued or not started and death followed this is lawful.
Enshrined in UK law is that principle of sanctity of life and the duty where possible and appropriate to preserve it. However, suffering is much broader as a concept than pain which, in the majority of court decisions, is set aside in favour of the actual medical prognosis. Lord Devlin argued that "no doctor, nor any man, no more in the case of the dying than of the healthy has the right deliberately to cut the thread of life"78. Patient autonomy during life is of no value if the patient cannot be autonomous in choosing the right to die. A right to life is of paramount importance in our contemporary paternalistic society. This eschews an autonomous right to die which, unless an equilibrium can be reached, presupposes that in fact humans do not have inherent rights; namely they are told what their rights are and believe that they are autonomously accepting them as natural law. The right to non-treatment or treatment elsewhere is not a right to die. It is a by-product from an omission. However the patient has to be considered "of sound mind" (see R v Z) in order for this "right" to be acceptable.
As seen in Michigan law, double effect is recognised as a type of euthanasia. However, we see euthanasia being legalised in courts by an omission (passive euthanasia). Double effect is somewhat more difficult as it is an act rather than an omission that kills the patient, despite the intention. Thus I would argue that although passive euthanasia is in fact legal, double effect is legalising a type of active euthanasia through the back door. Legally euthanasia is based on religiously absolutist principles, thus subsequently double effect cannot be morally correct as it violates these principles and could encourage "moral dishonesty"79. However, it would be negligent of the medical profession not to prescribe pain relieving drugs for the relief of terminal pain therefore the principle of double effect must be accepted regardless of whether it legalises euthanasia "through the back door".
Lord Edmund Davies, On Dying and Dying Well- Legal Aspects 1977
70 Proc Roy Soc Med 73
2 Pope John Paul II Papal encylical 14th Feb 2000"EVANGELIUM VITAE"
3 Handbook of Medical Ethics (London: BMA, 1984) pp 56 (BMA 329).
4 Summa Theologica (II-II, Qu. 64, Art.6).
5 ibid
6 R v Adams, Crim LR 365, 1957
7 Airedale NHS Trust v Bland p869C-E
8 Pace N & McClean S., Ethics and the Law in Intensive Care, Oxford University Press 1996 p63
9 Connell, FJ, Principles of Double Effect, New Catholic Encyclopaedia, New York: Mc Graw Hill, 1967
0 Kushe, H., Euthanasia, in A Companion to Ethics, Ed. Singer, P., Blackwells: Oxford 1993
1 Timothy Quill Roundtable Discussion 1997 Critique of the Double Effect
Monday, December 11th All Things Considered
2 R v A (No 2) 2001 UKHL 25 3 All ER 1
3 Mason & McCall Smith Law & Medical Ethics 5th Edition, Butterworths p437
4 More, T., Uptopia, Wordsworth Classics, 1997
5 Lord Joffe, Patient Assisted Dying Bill, Stationery Office
6 The Voluntary Euthanasia Society's Definition of Euthanasia
7 The Pro Life Alliance Definition www.prolife.org.uk
8 Euthanasia & physician assisted suicide: do the moral arguments differ? A discussion paper from the BMA's Medical Ethics Department April 1998
9 Report of the Select Committee on Medical Ethics, House of Lords Session 1993-94, Paras. 91-118, 236-241, 259-262 p114
20 Dr. Arthur's Case [1985] Crim LR 705
21 R v Cox, 12 BMLR 38 1992
22 Euthanasia & physician assisted suicide: do the moral arguments differ? A discussion paper from the BMA's Medical Ethics Department April 1998
23 R v Lodwig [1990] Lancet 335: 718
24 Pretty v UK, ECHR 2002 2 FLR 45
25 Lord Mustill, Airedale v Bland, 1 All ER 821 at 890 (1992) 12 BMLR 64 at 137
26 Re a ward of court (withholding medical treatment), Supreme Court of the Republic of Ireland 50 BMLR 140
27 Euthanasia: Normal Medical Practice? Have., H & Welie, J., Hastings Centre Report March-April 1992
28 Suicide Act 1961, s.2 Blackstone Statutes on Criminal Law 2005-2006
29 http://bmj.bmjjournals.com/cgi/content/full/321/7260/#B39
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31 Vacco & Others v Quill & Others, United 50 BMLR 119 1997
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48 House of Lords Select Committee on Medical Ethics 1994
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51 Report of the Select Committee on Medical Ethics, House of Lords Session 1993-94, Paras. 91-118, 236-241, 259-262 p113
52 ibid, pg 28
53 ibid p86
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55 R v C [1994] ER 819
56 Schloendorff v Society of New York Hospitals 105 NE92 (NY 1914)
57 Vacco & Others v Quill & Others United, 50 BMLR 119, 26 June 1997
58 Legal Aspects of Withholding and Withdrawing Life Support from Critically Ill Patients in the United States and Providing Palliative Care to Them
59 Re Quinlan 335 A 2d NJ 1976
60 Re J [1991] Fam 33, [1990] 3 All ER 930 p46C-D
61 Re J (A Minor) (Wardship: Medical Treatment) [1991] Fam 33, [1991] 1 FLR 366,
62 A National Health Service Trust v D [2000] 2 FLR 677, 47
63 National Health Service Trust v D Lloyd's Rep Med 411 [2000] 2 FCR 577
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66 Asch DA. The role of critical care nurses in euthanasia and assisted suicide. N Engl J Med 1996; 334: 1374-1379
67 References Battin, M. (1987). Euthanasia: the time is now
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70 R v A (No 2) 2001 UKHL 25 3 All ER 1
71 Gillick v. West Norfolk and Wisbech Area Health Authority [1986] AC 112, 190
72 Kennedy & Grubb, Medical Law: Texts and Materials, Lexis Nexis UK 2001 p1207
73 Timothy Quill, Rountable Discussion "Critique of the Double Effect" December 11th 1997, All things Considered
74 GLASS v UNITED KINGDOM (Application No 61827/00) European Court of Human Rights [2004] 1 FLR 1019
75 Select Committee on Medical Ethics 1994 pt 259
76 Paul J. van der Maas et al. Euthanasia, Physician-Assisted Suicide, and Other Medical Practices Involving the End of Life in the Netherlands, 1990-1995, New England Medical Journal, Volume 335:1699-1705 November 28 1996, No 22
77 Select Committee on Medical Ethics 1994, 442
78 Devlin, P 1985 Easing the Passing, Bodley Head, London: 165
79 Downie RS & Calman KC Heathly Respect, Ethics in Healthcare Faber and Faber 1987