The Court of Protection is due to consider the case of a woman known only as M, whose family wish for her to be (as the usual terminology has it) “allowed to die”. As so often in such cases, the effect of anonymity — designed to protect both her and her family — is to turn a real human tragedy into an abstract ethical conundrum. We know, however, that she is 53 and has been severely brain-damaged for the past eight years.
M is in what is described as a “minimally aware” state. This is one step up from a “permanent vegetative state” (PVS), which in turn is one step up from a coma. There is some disagreement among doctors as to what level of awareness she actually possesses, and in the present state of science no conclusive way of determining. Some argue that she is effectively unconconscious, others that she has enough awareness to communicate using a switch. Either way, though, she is not getting any better.
The case of M would break new legal ground. But ever since the case of Tony Bland in 1993, it has become almost routine to withdraw nutrition (water and nourishment) from patients diagnosed with PVS, at least where doctors and the patient’s family agree that there is no awareness and no hope of recovery.
The language used in these cases is made up of euphemisms — “allowed to die”, “right to die”, “death with dignity”, “withdrawal of treatment” — which disguise (or at least sidestep) what is really going on: the slow death by starvation and dehydration of patients who, to the best of medical knowledge, are not conscious and have no hope of recovery. No pet dog would be treated in such a manner. A dog would be “put to sleep” (another euphemism, of course); in other words, given a lethal injection. That is a quicker death, and a more honest one. For the purpose of withdrawing food and hydration is not a neutral suspension of treatment. It is a positive decision to “allow” someone to die. In fact, to kill them. If as a society we are to do such things, we should at least have the integrity to look them square in the face.
The law makes a clear but I would suggest wholly bogus distinction between “allowing” someone to die and killing them. The latter remains illegal, even in the case of assisted suicide where a person who is fully conscious and in command of their faculties makes a positive decision to end their life.
It would, of course, be open to such a person to refuse food and water and thus to die of dehydration. But such a prolonged and unpleasant death is rarely desired even by someone in the extremes of a terminal illness. This fact ought to concentrate minds on what is really going on when nourishment is withdrawn. The current state of the law rests on a form of moral hypocrisy in which the end is separated from the means: it is acceptable to will the end but not the means.
And so we have reached the morally absurd position in which the law allows someone to be killed without their permission – indeed, in a situation in which it is impossible for them to express an opinion — whereas someone who desires to die is prevented from acting on that desire. At the same time, the pretence is maintained that in the first case the person is not being killed, merely being allowed to die. The risk of maintaining society’s — and the doctors’ — morally clean hands is borne by the patient, whose consciousness is assumed to be absent though in truth it is impossible to be 100% certain, in every case, that the patient has no awareness.
A patient who was aware of what was going on, who felt the agony of being slowly starved of nourishment, would have no way of making that fact known. A patient who might, given medical advances, one day recover and who might wish to be afforded that slim chance, equally has no way of expressing that preference. (Even today, it is not unknown for a patient to emerge from a diagnosis of PVS.) The court, in allowing the withdrawal of treatment, not only sentences the patient to death, but sentences them to what is potentially a cruel death. And this is viewed as acceptable by many people who would feel outraged if the court went one stage “further” and instead decreed a quick and pain-free termination.
Moreover, while assisted suicide continues to be the subject of fierce public debate, for almost twenty years it has been settled practice to kill (in all but name) patients who have become a burden to their relatives and the health service, who may be unconscious but whose long-term prospects are unknowable. I find this state of affairs distinctly odd.