by Oenone Wollaston
for the NW region day conference, Nov 2007

Hippocratic Oath

My own experience has largely been in General Practice which involves dealing with patients at every stage of the life course. However for this paper I have chosen to concentrate on end-of-life issues. General practice is at the heart of health services around the world and GP's are the first point of contact for the patients. They have multiple obligations:

  • To patients in their care.
  • To governments for the responsible use of resources.
  • To the wider community for the standard of health care they provide.

General Practice is ethically significant and complex although it is set in apparently mundane everyday experience...We are bound by the Hippocratic Oath which obliges us to help and not to harm patients, while a recent GMC booklet on the "Duties of a Doctor" makes the care of patients our first concern.

The Doctor-Patient relationship in General Practice has TRUST at its core...CONFIDENTIALITY is central to that relationship which entails honesty, compassion, integrity and justice.

Patients should be fully informed and have the information necessary to make a decision. They should not be coerced and their decisions about treatment should be respected.

Asking "What is the right thing to do in this situation?" may involve proceeding to an action which seems the lesser of two evils. Do the consequences of an action determine its morality, or the intrinsic features of the act? A balance has to be found between acting for the good of the patient and respecting their rights.

In the last 50 years the doctor/patient relationship has changed and patients now have a greater say in their treatment. However, there are limits to autonomy, and rights also include responsibilities.

Suicide

Literally "Self-Killing" since the person concerned considers life no longer worth living. Historically suicide has been viewed as an evil action...an offence against the moral law and often the relevant code of criminal law. Many countries - including the UK - have now decriminalised suicide, but helping another person to die remains an offence.

Although no longer a criminal offence Suicide should not lessen the respect for human life which we all share. It is a bad type of action resulting from lack of hope, despair, anger, grief and hatred. It can be understood but its consequences are irreparable.

Assisted Suicide/Euthanasia

Euthanasia literally means "good death"... it is the intentional ending of a life to relieve suffering... i.e. the life is cut short.

The BMA unreservedly condemns euthanasia though it now accepts abortion.

In this situation the wellbeing of the patient must be considered. They must be encouraged to discuss their fears...of pain, of loss of dignity, of loss of control, of becoming a burden. The patients, or their carers if that is more appropriate, must be full informed. The patients should be able to make significant decisions about their own lives. Sometimes the burden of life outweighs the benefits. Patients have an absolute right to refuse treatment, even life-saving treatment, but they do not have a right to ask the doctor to give a specific treatment that will end life.

Belief that killing is wrong has deep roots in our society. This is referred to as THE SANCTITY OF LIFE DOCTRINE... the idea that life is a gift which humans do not have a right to destroy.

Medical care aims to relieve suffering for those who have intolerable symptoms of uncontrolled pain.

Given the current illegality of Euthanasia in the UK, any compassionate acts to end life are above and beyond the call of duty. A patient's autonomy, therefore, has limits.

Voluntary Euthanasia and Non-Voluntary Euthanasia

These can be classified with active and passive euthanasia... "Allowing Nature to take its course"... How important is the moral difference between an act and an omission? Motive is all-important.

Killing and Letting Die

Is this difference always clear? E.g. Down's Syndrone... Does "Nursing Care Only" mean killing by omission where there is a duty of care? Also compare these cases... (a) Mrs B, age 43, paralysed for 12 months and on a ventilator but mentally competent... The Judge ruled that her ventilator could be turned off. (b) Mrs P, age 43, requested suicide with her husband's help...  request denied.

In 1936 Lord Dawson, Physician to King George V, gave his patient morphine to ensure that he died in time for an announcement in the morning papers. "Double Effect"... object the relief of pain, but the result may be death...which is imminent anyway.


Dr Oenone Wollaston is a Christian GP with a special interest in geriatrics and end-of-life issues.