The last half century has been a time of greatly increased personal choice. As regards health, doctors may truly claim to have provided significantly greater choice in everyday life. We live longer and can delay death yet further by choosing lifestyles known to be healthier, by prophylactic cancer screening and treatment and by techniques such as coronary bypasses. Therapies, such as hip replacements, can improve the quality of life. In the last forty years we have had, for the first time, effective contraception. Women can reliably delay or prevent pregnancy, resulting in the average age at first delivery being startlingly increased. Couples with fertility problems have a vastly greater chance of the pregnancy they seek.
Our legislators have followed the same path. The law allows us far greater ethical choice. Abortion is a legal and available course of action. The choice, if choice it is, of sexual orientation is protected by the homosexual reform law. Sexual equality is approaching and unusual family patterns are far more open and largely accepted by law and by society.
Strangely the choice of how and when we wish to die is still restricted and unclear. Suicide ceased to be a crime in 1961 but aiding and abetting someone trying to commit suicide remains criminal. In Germany and German-speaking Switzerland, assisting a suicide is not illegal and in these countries a doctor, or indeed anyone else in possession of suitable drugs, may give them to a would-be suicide so as to allow the act to be done in a dignified manner. In 1985 an amendment to the Suicide Act was presented to the house of Lords which would have allowed such aid in the UK with the proviso that the person who assists a suicide must be prepared to show that the aid was given with compassion and in good faith. It was not enacted.
We all retain the right to refuse recommended treatment even when terminally ill and when such refusal is effectively suicide. Doctors are allowed to aid passive euthanasia and may withhold treatment offering the sole hope of life but they may not perform active euthanasia and comply with a patient’s request to be killed. Problems arise with patients so ill that they can no longer effectively communicate, or when they have become mentally incompetent. Of recent years the concept of the Advance Directive has been developed. It seeks to give clear expression to the individual’s considered wish, while of sound mind, in the hope firstly of influencing future medical decisions, and secondly, of offering some measure of legal protection to any doctor implementing them. Until recently the Advance Directive has widely been regarded as advisory only and without legal status; however at the recent Bland Appeal it was informally stated that all counsel involved had agreed that the right to refuse treatment already extended to the right to decline it in advance. Very recently the Law Commission report on ‘‘Decision Making and Incompetent Adults’’ has come out in support not only of the principle but of legislation. In a most significant change of heart, the British Medical Association published in May 1993 a statement strongly supporting the principle of the Advance Directive.
Both the House of Lords and the House of Commons are shortly to debate Bills aimed at giving the force of law to a properly constituted Advance Directive. In March 1993, Lord Allen of Abbeydale presented the Medical Treatment (Advance Directive) Bill with the short title ‘‘An Act to enable persons to give directions (or arrange for them to be given) to their physicians regarding the withholding or withdrawal of life-sustaining treatment in a terminal condition, and for related purposes.’’ In June 1993 a Bill with the short title of ‘‘The Voluntary Euthanasia Act 199-’’ was presented before the House of Commons by Piara Khabra MP and passed its first reading. This Bill goes much further and seeks to legalise true Euthanasia where the patient had, not less than 30 days previously, made an Advance Directive asking for death under the ruling circumstances. The doctor’s actions would not constitute aiding and abetting suicide under the Suicide Act 1961. Both Acts would preserve doctors’ rights to refuse to act against their conscience but would, effectively, force all doctors to declare their position to their patients. It is considered likely that Lord Allen’s Bill may finally be enacted. The passage of either or an amalgam of these bills would effectively extend individual freedom of choice into the last bastion of medical paternalism: the mode and timing of death.
Peter Diggory