'Thou shalt not kill, but needst not strive officiously to keep alive'

This much quoted couplet was not originally a piece of ethical dogma but part of a nineteenth century satirical poem which, working one by one through the Commandments, rebuked hypocritical Victorian churghgoing society for its double standards. 'It's wrong to kill by commission' the satire acknowledged, but suggested society thought, 'it's okay OK to kill by omission'.

I agree with the first but not the second, yet outside of the satire, this couplet may unwittingly have summarised the balance we need to sustain today in the complex technology-surrounded healthcare decisions around withholding and withdrawing life-prolonging treatments.

Thou shalt not kill
Euthanasia has been defined as 'the intentional killing by act or omission of a person whose life is felt not to be worth living'. Where intentional killing by act is concerned, euthanasia is widely seen as unethical and is illegal in the UK. The recent flurry of publicity when the Netherlands finally legalised what it had been doing for decades will not alter this.

The ethical and legal position when omissions are associated with the deaths of patients is less clear, but the concept of intention is critical. Intention is a simple idea. It's about 'What?' questions. What did the health professional mean to do when she performed the act? What did the health professional mean to do when she omitted to act? It's not so much about motive, about what was running through the professional's mind and heart at the time; it's a simple 'What?' question. If the intention was to end the life of a patient, that was unethical, and illegal in the case of an act. If the intention was to end the life of a patient, that was unethical and arguably illegal in the case of an omission. (And is an omission an act?)

But needst not strive…
We must accept life has a natural end, and there is no obligation to use every possible technological treatment on every patient in every situation just because those treatments exist. That never has been a goal of healthcare, is not now, and never should be!

Healthcare traditionally has had two contrasting obligations, operating as the two sides of a coin. One is to preserve life and prevent death - which is about quantity. The other equally important obligation is to relieve suffering - which is about quality. The prioritising of these two obligations depends on all the circumstances of the individual case.

If the patient is approaching the end of his natural life, so that the inevitability of death cannot be postponed for very much longer, then the goal of healthcare moves away from trying to preserve life and prevent death (at almost any cost) and towards the relief of suffering, towards palliation and quality of life in the increasingly precious time that remains.

It is in this sense that the Victorian couplet rings true - we 'needst not strive officiously to keep alive'. If the intention of withholding or withdrawing a potentially life-prolonging treatment is to spare the patient (and perhaps his family too) an inappropriate burden and thereby to maximise the quality of life, that is entirely ethical and entirely lawful.

If the intention is to kill by omission, that is unethical and depending on the clinical issues involved, might well be unlawful.

and finally…
The real issue in the debate about end-of-life issues is that discussion of death is a taboo in our society. High technology healthcare has forced out consideration of the spiritual, yet almost all patients approaching the ends of their lives ask spiritual questions: Is there anything after death? Where am I going?

Society needs to re-examine these age-old questions as part of holistic healthcare, and is confident Christianity will not be found wanting in its answers.

Dr Fergusson is Head of Policy at the Centre for Bioethics and Public Policy and Medical Adviser to CARE.

email: drandrewfergusson@tinyworld.co.uk

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