21. Doctors to Decide on Right to Die

Doctors alone must make the final decision whether to withdraw treatment, including artificial feeding, and allow a terminally ill patient to die, according to British Medical Association guidelines published yesterday.

They must consult the family, take into account views of the patient and get a second medical opinion. But ultimately the responsibility rests with the doctor, and if the family disagrees it can only challenge his or her decision in the courts.

Members of the BMA's ethics committee, which produced the guidelines, said they were not a charter for euthanasia.

"This is not about intending to kill people. It is about intending to withdraw what people believe to be useless or non-beneficial interventions," said Raanan Gillon, a GP and professor of medical ethics at Imperial College, London. "It is the difference between foreseeing death as the outcome and intending it."

Opponents of euthanasia rejected this distinction. "I am deeply concerned that some doctors might interpret the guidelines to increase the number of unnatural deaths," said Dr Andrew Fergusson, chairman of the pressure group Healthcare Opposed to Euthanasia.

"I recognise these are very difficult matters, but am anxious about even more power being given to doctors in the apparent absence of adequate safeguards. This guidance will be bad for some patients."

The BMA has produced the guidelines because of confusion and uncertainty among doctors over how to proceed when treatment is doing more harm than good—perhaps in the case of unsuccessful chemotherapy for cancer—or when a patient is incapacitated after a severe stroke or advanced dementia.

The House of Lords judgment in the 1993 Bland case has muddied the waters. Tony Bland was in a persistent vegetative state (PVS) after the Hillsborough disaster. The courts backed the BMA view that the artificial feeding and hydration through a tube that were keeping him alive were medical treatments.

His father won permission to have all treatment stopped and his son was allowed to die. But the Lords stated that their ruling applied only to patients in PVS and suggested each case should be referred in turn to the courts.

The BMA guidelines make clear that they feel there is no such need in cases other than PVS. These are hard decisions, but doctors are well qualified to make them. If the decision involves stopping artificial nutrition and hydration, which the document accepts is an emotive issue, then a second opinion from a specialist unconnected with the case must be sought.

The doctor must try to ascertain the patient's own wishes. The views of children under 16 who are capable of understanding must be respected and their parents' views sought. Living wills requesting no further treatment must be complied with.

With patients who cannot communicate, doctors must consider among other things whether the invasiveness and pain of treatment are justifiable, how likely is any improvement and how aware patients are of the world around them.

The document accuses society of "unrealistic expectations ... about the extent to which it is possible to postpone death."

But SOS-NHS Patients in Danger, a pressure group formed by relatives of patients who have died in hospital, rejected the guidelines outright.

It said: "A terminally ill patient, with weeks, months and (who knows) even years to live would not benefit from having their death hastened for the convenience of medical staff and managers when they and their family might have other plans for how they wish to spend their precious remaining time together."